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Home My WebLink About885 JUNIPERO DR - Building Permits� CITY OF COSTA MESA � a�` FS BIIILDING DIVISION i`�� 77 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • v-nvw.ci.costa-mesa.ca.us : ��o FOR INSPECTIONS CALL: (714) 754-5626 � PERMIT TYPE APN: 14134243 Zoning: , PERMIT NUMBER: B MISC STATUS: DATE ISSUED: ISSUED BY: JOB ADDRESS: 885 JUNIPERO DR CM Vicinity: ANGELSPLAYGROUNDATTEWINKLEPARK vv SQ. FT: 0 Valuation: Suite/Unit: Primary Occ: 50.00 BX07-00065 ISSUED 01/10/2008 BJK Const Type SCOPE OF WORK: , CONSTRUCTION OF 3 GAZEBO AND 4 PICNIC SHADE1SHELTERS AT "ANGELS PIAYGROUND" AT TEWINKLE PARK. REF.: BC07-00164 OWNER: CITY OF COSTA MESA Ciry/State: COSTA MESA, CA Phone: APPLICANT: GUSTAVO ZAZUETTA City/State: Phone: 714-325-3268 CONTRACTOR: MICON CONSTRUCTION INC Address: 1616 SIERRA MADRE City/State: PLACENTIA, CA Zip Code: 92870 ARCHITECT: Phone ENGINEER: DAVID S DAYTON, III Phone Building Plan Check: Building Permit: Electrical Permit: SMIP Residential SMIP Commercial $O.00TOTAL FEES Address:: P 0 BOX 1200 Zip Code: 92628 Address: Zip Code: License No. 744198 Phone 714-666-0203 FEE SUMMARY $o.00 $0.00 $0.00 $0.00 $0.00 $0.00 License No. License No. C045618 Unit Unit ,� Unit: Cell: I�� r.�l. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulalions. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMI7 EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must wmply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. 0 R INSPECTIONTYPE D�TF IN71TRL5 COOEp INSPELTIONTYPE pATE INPTIALS 7616 Fixed System Final Fire Preven�ion 1266 Pool Spa Final . 200 Final Re-Roof 201 Final Block/Relaining Wall 202 Final Faclory Fire place 203 Final Si9n 204 FinalOemolifion 206 Final Mechanical 208 Final Plumbing 210 Final Electncal 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Fnal Building/Occupancy �L- �--[=L�IL � WORKERS' COMPENSATION DECLARATION: � I hereby aKrm under penalty of perjury one ot the lollowing declarations: ❑ I have antl will maintain a certifcate of consent to selhlnsure for vrorkers' tompensalion, a5 provitle0 for Dy SeCtion 3700 0( thB LahOr Cotle, for lhe peAormance of the vrork for which this pertnit is issued. � I have and will maintain wnrkers' compensation insurance, as repuired by �section 3700 of the Labor Code, for the peAormance ol the work for which this pertnit is issued. My workers' compensation Insurance carner and policy number ra e: �� ^ �� Ca❑ier:l�C� OF irvUJ6�oi n� 0�15 (T�issed' needno1f16emmde�etlAthepemutkvalue0alonehwrtl�etlOaMarsf5t001orless) Policy Number. 'Y ��,5 � a�{ � ❑ I certify th9,.C� in the peAorman o! the vrork !or which this permit is issued, I shafl�ndt employ any pers in any manner so as to become subject b the worliers�compensation la /of California, and agree that if I should become�su6Jee1 to the workers cpmpensation provisions of Seclion 3700 of the La/yor Co I shall fort/F/�nth ¢omply vnth these provisions. l/ �/ , � ! l� /k �' �� '�� WARNING: FAILURE SECURE WORKERS' COMPENSATION COVER4GE IS UNLAWFUL AN SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE fABOR CODE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrm that I am licensetl under provisions ot Chapter 9(commencing with Section 7000) of Division 3 ot the Business and Pmfessions Code, and my license is in full (ocrce and eftect. � /� Lic. # � / Class # /' � �� ,/-/o� ofi Contracto' Signawre Date CONSTRUCTION l NDING AGENCY: � I hereDy aKrtn that there is a constructbn lentling agency fa the peRwmance ot the v.ork fa wfiich tNs pertnit is issued. (Sec. 3097. Civil Code). Lender's Name: Lender's Address: SgnaWre Oale OWNER-BUILDER DECLARATIONS: I hereby aHirm Ihat under penalty of perjury thal I am E7(EMPT FROM THE CONTRACTORS LICENSE LAW for Ihe following reason (Sec. 7031.5, Business and Professions Code: Any ciry or county which requires a permit to construcl, alter, improve, demolish, or repair any sWclure, prior to its issuance, also requires Ihe applicant for such pertnil to file a signed statement that he or she is licensed pursuant [o lhe pmvisions of Ihe Contractors License Law (Chapter 9(commencing wi[h Seclion 7000) of Division 3 of the Business and Protessions Code) or that he or she is exempt therefmm and the basis for the alleged exemptioa Any violation ol Section 7037.5 by any applicant for a permit subjects the applicant lo a civil penalry of not more than five hundretl dollars ($500).�: ❑ I, as owner of the property, or my employees with wages as their sole wmpensation, WILL DO 7HE WORK, and the sWclure is not imendetl or oftered for sale (Sec. 7044, Business and Professions CoOe: The Contractors License Law does not apply lo an owner of property who builds or improves the�eon, antl who does such vrork himself or hersel( or Ihmugh his or her ovm employees, provided that such improvements are nol intended or offeretl for sale. If, however, the building or improvement is soltl within one year of completion, the owner-builder vnll have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH UCENSED CONTRACTORS to consWct ihe project (Sec. 7044, Business and Professions Code: The cont2ctors License Law dces not apply to an owner of propetly vfio builds or improves thereon, and wfio conlracts for such project with a cmtracta(s) license pursuant to the Cont2ctors License LawsJ. ❑ I am exempt under sec. Business and Professions Code for this reason: ' Slgnalure Daie 305]-46 (3/0]) Ovmer ID verifetl Dy tlnvei� ❑ Yes ❑ No Dnvers License No. Expires: Verification of Ovmership by (lype o! document, i.e. - property lax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certdy that no excavation frve (5) or more feel in depth iNo which a person is requiretl to descend, vrill De made in conneclqn vrith work authorized by this pertnit, and that no builtlinq sWcture, scaffdding, falsework, ar demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 32, Grp 2. M 2, $CL. 341, T1112 8, i�,311(Ofllld fidffllfll5�f2IIV2 COdE�. ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division o! Intlustrial Safery, as noted above, unless such person has a permit lo do such work from Ihe division. Appl¢anfs SignaWre Dalc Division of Indushial Safety Permit Numbec HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the appliwnt or present or fuWre building occupant need to file and certify a� Business Plan tor emergency response ro release or threatened release of a hazardous matenall ❑ Yes ❑ No (Section 25505 of the Califomia Health and Sa/ery Code requires. with some exceptions, that a Business Plan De filetl with the Costa Mesa Fire Department by every business v+hich has at any one time during a reportetl year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at slantlard lemperature an0 pressure). 2. Does or will the applicant or present or future building occupant need to fle a registration fortn for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safely Cotle, with some exceptions, requires regislration with the Costa Mesa Fire Departmen[ by each business which at any one time has on hantl a quanti[y o( acutely hazardous materials equal ro or greater than a weight ot 500 pounds, or a volume o( 55 gallons, or 200 cu�ic feet of compressed gas at standartl temperature and pressure). 3. Does or will Ihe applicam or present or future builtlinq ocwpant neetl to prepare an RMPP (Risk Management and Prevention Program for acutely hazartlous materials)7 ❑ Yes ❑ No (Seclion 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, cetli(cation antl filing with the Fire Department of an RMPP by businesses which are required lo register acutely hazardous matenals with the Fire Department. 4. If an RMPP is presentty required, has Sec[ion 25534 of Ihe California Heallh antl Safety Cotle been fully complied with? ❑ Ves ❑ No 5. Does or will Ihe applicant or present or fuNre building occupant require for the work which is lhe subject of Ihis application a permit (or such consl�uclion or modi(cation trom Ihe South Coast Air Quality Management District or trom any other air pollution control distncl or agency? ❑ Yes ❑ No (Section 658502 of lhe Califomia Govemment Cotle requires that the requestetl information be fumished on applications for non-residential building pertnits). 6. Will any part of lhe (aciliry to be consWcted under Ihis permit be within 7000 feel (rom the ouler boundanes of a school? ❑ Yes ❑ No pf yes", the facility musl mee� I�e requirement of Sections 25534 an0 42303 of the Califomia Health and Safety Code). 7. If a permit from the South Coasl Air Quality Management DisMcl or other air polWtion control tlis�nct or agency is required for Ihe work which is Ihe suDject of �his application, have all ot the disclosures prescnbed by Califomia Health and Safety Code Section 42303 been made? ❑ Ves ❑ No 8. (If yes", attach certificate of compliance from the appropriate air polNtion control oKcer). CERTIFICATE OF COMPLIANCE: I certify that under penalty o( perjury the information given above is correcL I agree to comply with all state laws and ciry ordinances regarding Hazardous Materials and Emissions. Signalure Date / / CERTIFICATE OF COMPLIANCE AND AUTHORVATION OF ENTRY: I r certify under penalty of perjury that I have read this application antl state that the infortnation given is correct. I agree to comply v+ith all stale laws antl ciry ordinances relatin9 to building construction, and authorize representatives o( ihe City of Cos M a to enter upo the above-describetl property tor inspection purpo es. agree not to occu y or allow occupancy of any building authonzed by t s/pe� until final insp tion. Dale /-/U_ �� Daie • , � � CITY�'COSTA MESA � , Fa BIIILDING DIV/SION F. . � 77 FAIR DRNE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (71Q�,7��I • a 07-00511 °.4�� FOR INSPECTIONS CALL: (714) 754•56 , PERMIT TYPE: B COMBO STATUS: APPLIED Sub Type: DEMO_ALL DATE ISSUED: ISSUED BY: �oe a�oReSs: 885 JUNIPERO DR CM Suite/Unit: APN: �at3a2a3 Zoning: , , Vicinity: � � � Primary Occ: Const Type: ,�:-, SQ. FT' --, � . 0 � � , . Valuation: $9,000.00 SCOPE OF WORK: DEMOLISH EXIS7ING 900SF ftESTROOM FACILITY AND REMOVE CONCRETE SIDEWALS. AND PLY GROUND EQUIPMENT FOR FUTURE DEVECOPMENT. AND CAP SEWER OWNER: CITY OF COSTA MESA � Address: P O BOX 7200 �., � �- UniL' Phone: ,- - �� CitylState/Zip: COSTA MESA, CA , � APPLICANT: GLENN BELL �- _. Address: � 2459 LEE AV Phone: Q26350-8303 � _ � ` City/State/zZip: SOUTH EL MONTE � - CON7RAcrOrt: AMERICAN WRECKING INC � � License No. 685192 Phone: 626-350-8303.� " . � � Address: 2459LEEAVUnit> Cell: . , City/State: SOUTH EL MONTE � ARCHITECT: � License No. ENGINEER: _ , � License No. COMBINTATION;PERMIT FEE SUMMARY Building Plan Check: ' �� . $0.00 Building Fees: $0.00 Electrical Fees: - � � � � $0.00 - Mechanical F�es: -� - �_ $0.00 � . : Plumbing Fees; ` $0100 SMIP Residential: , $0.00 . SMIP Commercial: � � . $0.00 � � TOTALFEES: $0.00'� -- "Re(er to fee receipts for all fees paid tor pro�ect' . • ., , Unit: : � ZipCode 91733 PHONE:' PHONE' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. G �E t. INSPEC710N rypE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 FinalRe-Roof 201 Final Block/Relaining Wall 202 Final Factoy Fire Place 203 Final Sign 204 Final Demolition �ATE INTITIALS "Z "� (Q'ryl'i LOOEN INSPECTIONTYPE DATE INTITIRLS 206 Final Mechanical �� /� � 20B Final Plumbing � A'�D�f �Lts V_ L7 -o'� P�"�'W �� r 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site _ _ 250 Final Building/Occupancy . WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one o( the follovnng declarations: ❑ I have antl will maintain a certificate of consent to seR-Insure for workers' compensation, as providetl for by section 3700 of Ihe Labor Code, for the pe� rmance of the work for which ihis permit is issued. �❑ I have and will maintain woAcers' compensation insurance, as required by section 3700 of the Labor Code, for the pedormance of the vrork for which this pertnit is issued. My workers' compensation Insurance carrier and policy number are: Carrier — % �/�y (T�is secf.vn ne'M rq1 be mmp'efetl ilthe permn k va�lu/e0 al one huMretl tldlars (Sf 00) w less ) �icy_Number. � _ ;(%—��'��.�y-.fl� �I certify �ha[ in the pertormance of the work for which this pertni� is tl, I shall no[ employ any person in any manner so as to become subject to the vrorkers' compensation laws of Cali(omia, and agree that if I should become subj eJ to ihe worker ' ensation provisions of Section 3700 of the Labo E, I shall forth� ' ly with these provisions. , /Z � -�% AppGqnfsSignaNra - �'Dale / WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED POR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND AiTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affrm that I am licensed under provisions of Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions�Code, and my license is in full force and effect. .� : � , , Owner ID verified by drive �0 Ves ❑ No — - ` , s 3 r-�g �D`river's License No. '� �F�cpires. -'�'' Venfication o! Ownership by (rype of document, i.e. - property tax hill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certi(y that no excavation frve (5) or more (eet in dep[h into which a person is required to descend, will be matle in connectbn with work aNhonzetl hy this pertnit, and ihat no building strucWre, scaffolding, (alsevrork, a demolition or tlismantling Ihereol, will be more Ihan Ihirty-six (36) fee[ high. (Chap. 32, Grp 2, M 2, Sec. 341, Tlle 8, Califomia Adminis[rative Cotle). ❑ As ovmer-builder, I will not employ anyone to do work vfiich would require a permit from ihe Division of Induslrial Safety, as no[etl above, unless such person has a permit to do such work from Ihe division. Applitanl's SignaWre Dale Division of Industrial Sa(ety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or luture builtling occupant neetl to fle antl certify a Business Plan for emergency response ro release or ihrea[enetl release of a hazardous malerial? ❑ Yes ❑ No (Section 25505 of the Cali(omia Health and Safety Code requires, with some exceptions, that a Business Plan be filetl with Ihe Costa Mesa Fire Department by every business which has at any one time during a reported year a quantiry of hazardous materials equal to or greater than a vreight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or presen[ or fuWre builAing occupan[ need to fle a registration form for awtel hazartlous materials� ❑ Yes ❑ N y o Cic. # 5 (-Class # �—� I (Section 25533 of the Califomia Health and Satety Cotle, with some excep[ions, requires registration with Ihe Costa Mesa Fire Departmen[ by %�—�� each business which at any one time has on hand a quan[ity of acutely � Contradar's5ignature oace y ( hazartlous matenals equal to or greater than a weight of 500 pounds, or a �- � � �-- � volume of 55 gallons, or 200 cubic feet of compressed gas at standard CONSTRUCTION LENDING AGENCY: ❑ I hereby aKrm Ihat Ihere is a consiruction lending agency for Ue peAortnance of the vrork for which this pertnit is issued. (Sec. 3097, Civil Cotle�. Lender's Name: Lender's Address: OWNER-BUILDER DECLARATIONS: I hereby affirm that under Denalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any ciry or county which requires a permit �o cons[mct, alter, improve, demolish, or repair any struc[ure, prior to ils issuance, also requires [he applicant for such permit [o fle a signetl statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9(commencing vrith Section 7000) of Division 3 0( the Business and Professions Code) or that he or she is exempt Iherefrom antl the basis for the alleged exemption. Any violation of Section 7037.5 by any applican[ for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as ovmer of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the sWcture is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contracbrs License Law does not apply to an owner of property who builds or improves thereon, and who does such vrork himsel( or hersel� or thmugh his or her own employees, provided Ihat such improvements are not intended or offered for sale. If, however, ihe building or improvement is sold within one year of completion, the ovmer-builder will have the burden of provinq that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to const�uct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an ovmer of property who builds or improves thereon, and who cont2cts for such project with a contrector(s) license pursuant to the Contractas License Laws.). �.. . . ❑ I am exempt untler sec. Business and Professions Cotle (or this reason: 305]-a6(3I0)) temperature antl pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Managemenl and Prevention Program for awtely hazardous malenals)? ❑ Ves ❑ No (Seclion 25534 of Ihe California Health and Safety Code provides that ihe Costa Mesa Fire Departmenl may require the preparation, certification and fling with the Fire Department o( an RMPP by businesses which are requiretl to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of �he Cali(omia Healih and Sa(ety Code been fully complied wi[h? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit /or such construction or motlifcation �rom the South Coas[ Air Quality Management Distric[ or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 658502 of Ihe Califomia Govemment Cotle requires �hat the requested information be fumished on applications for nornresitlential building permits). 6. Will any part of the facility to be constmcletl untler [his permit be within 1000 feet from Ihe outer boundanes of a school? ❑ Ves ❑ No Qf'yes", [he facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Cotle). 7. If a permit from Ihe South Coast Air Quality Management District or other air polWtion contml disVict or agency is required for the work which is the subject of this application, have all of the disclosures prescnbed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. Qf "yes", attach certificate of compliance from Ihe appropnate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalry of perjury Ihat I have read this application and slate that Ihe information given is correct I agree to comply wi�h all state laws and city ortlinances relating to building consVuction, and authonze representatives ot the Ciry of Costa Mesa to enter upon [he above-described property (or inspection p r I agree not t� py or allow occupanty o( any building authorized ' permit until fi � s e6%n. � /2-�' �o 'Signature of Leg 1 vm �Date_ J AnClor Aut�onzetl Apphranl w SOUI n COAST AIR QUALITY MANAGEMENT DISTRICT NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL MAIL FORM AND FEE TO SCA�MD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES, CA. 90074-5641 AQMD USE ONLY SCREEN BY RECEIVED POSTMARK ENTERED BY NOTIFICATION # COMPLETEDBY RebeccaAmbriz COMPANY American Wrecking, Inc. PHONE (626)350-8303 DATE 12/12/07 CHECK# FEE $ PROJECT# A07-133J NOTIFICA710NTYpE ORIGINAL REVISIOMDA7ES REVISIONOiHER(highlghf) CANCELLATION PROJECT TYPE DEMOLITION ORDERED DEMOLITION RENOVATION(removal) EMERGENCY REMOVAL PLANNED RENO(annual) SITE INFORMATION SITE NAME Tewinkle Park SITE ADDRESS 885 Junipero Dirve CROSS STREE7 Presidio Drive CITY Costa Mesa STATE CA ZIP 92626 COUNTY Orange County DESCRIBE WORK LOCATION Demolition of Structures and Site Clearing BUILDING SIZE(SQ FT)300 sqft NUMBER OF FLOORS BUILDING AGE (YEARS; 15+ NUMBER OF DWELLING UNITS BLOG PRIOR I PRESENT USE COMMERCIAL HOSPITAL INDUSTRIAI OTHER OFFICE PUBLIC BLDG. HOUSE SCHOOL SHIP UNIV/COLLEGE SITE OWNER City of Costa Mesa ADDRESS 77 Fair Drive CITY Costa Mesa STATE CA ZIP 92626 CONTACT Battazar Mejia PHONE (714)754-5045 P'"`UIREDBUILDING nsflesios YF,S No nseesrOs YES NO nSeESrOS YES No BUILDINGTOBE YES NO ,iMAT1ON pRESENT7' SURVEV9 REMOVED7 DEMOLISHED? PROJECT DATES START 01/03/08 END 01107/OS WORK SHIFT(day, swing, night) 7am �0 4 pm `ASBESTOS AMOUNT TO BE FRIABLE CLASS I CLASS II TOTAL REMOVED (add row) REMOVED (in square feet) `ASBESTOS REMOVAL FROM SURFACES PIPES COMPONENTS 'AMOUNT OF EACH TYPE OF ACOUSTIC CEILING uNOLEUM INSUTAiION FIRE PROOFING DUCTING STUCCO MASTIC ASBESTOS (in square feeq FLOOR TII.ES (VAT) DRV WALL PLASTER TRANSITE ROOFING OTHER (tlescribe) CONTRAC70R iNFpRMA710N CSBL LICENSE # 685192 OSHA REG # AQMD ID# 97316 NAME AmeriCan Wrecking, Inc. ADDRESS 2459 Lee Avenue CITY South FI Monte STATE CA ZIP 91733 SITE SUPVR Jerry Galaviz PHONE (626) 350-8303 WASTE TRANSPORTER #1 LANDFILL Puente Hills ADDRESS ADDRESS 2800 Workman Mill Rd CITY STATE ZIP CITY Whittier STATE CA ZIP 90601 equired for demolition notifications asbestos surveys are required prior to Demolition and Renovation. Forms, instmctions, and the Rule 1403 can be obtained from AQMD we site http://www.aqmd. gov aage i oi z Form REV 20040623 . SCAQMD �._ i IFICATION OF DEMOLITION OR ASBESTOa rtEMOVAL MAIL ORIGINAL TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE #55641, LOS ANGELES CA 90074�5641 �TE TRANSPORTER p2 AUURESS CITY STATE ZIP )CITY � STORAGE SITE SiATE 21P 'CONTROLS: DESCRIBE WORK PRACT!CES AND CONTROLS TO BE USED AT THE RENOVATION AND DEMOLITION SITE. Procedure #1, 2, 3, 4, 5, or Other. For asbestos removals circle the combination o( Rule 1403 procedures used. Procedure 4 and 5 submit plans for A�MD prior approval. 'ASBESTO$ DETECTION PROCEq�RE: CIRCLE THE PROCEDURES AND ANALYTICAL METHODS USED TO DETERMINE ASBESTOS IN THE BUIIDING: 8ulk Samplinc�, Inspection, Survey, PLM, PCM, TEM, Assumed as Asbestos, Describe Other: FOR DEMOLI70NS G1VE THE COR7PANY NAME AND DA7ES OF THE ASBES70S REMOVAL: Argus Contracting FOR ORDERED DEMOLITION SEND A COPY OF THE ORDER AN GIVE THE AGENCY NAME 8 PHONE # AUTHORIZING PERSON: 7�7LE: DATE OF ORDER: IDATE ORDERED TO BEGIN: Oale Decomber 07 'FOR EM1fERGENCYASBE5T05 REM6VAL GIVE THE NAME AND PHONE NUMBER OF THE PERSON DECLARING/AUTHORIZING THE EMERGENCY, DATE AND HOUR OF EMERGENCY AND DESCRIBE THE SUDEN, UNEXPECTE� EVENT: EXPLAIN HOW THE EVENT WOULD CAUSE UNSAFE CONDITIONS, EQUIPMENT DAMAGE OR UNREASONABLE FINANCIAL BURDEN: CONTINGENCYPLAN: DESCRIBEACTIONSANDPROCEOURESTOBEFOLlOWE01FUNEXPECTEDASBESTOSISFOUNODURINGDEMOLITIONORNONFRIABLE 'STOS MATERIAL BECOME CRUMBLED, PULVERIZED, OR REDUCED TO POWDER. SiOa oEMOUTiON WORK IMMEDiA7E�v nNo NO7iFY qpMD. 'TRAINING CERTIFICATION; i Cenify that an individual trained in the provisions of regulation AQMD Rule 1403 and NESHAP will be on sile during the removal end evidence thal lhe required iraining has bean accomplishetl by Ihis person will be available for inspeclion tluring normal business �ours. INFORMATION CERTIFICATION: I certify that the above information is correct and I American Wrecking, Inc. Rebecca Ambriz CompanyName p,;,,�,,,m,,,r„w, Ti�le o� owne any required attachments. Pmject Coordinator Notifications can not be accepted without the required fee ( Rule 3011. Ashestos removals of Iess tha 100 square feet are exempt from notification and fees. Please make check payable to "SCAQMD". Fees are per notification, not refundable, and vary according to the project size. Fees are as Follows: PROJECT SIZE in (t DEMOLITION OF REMOVAL 1,000 or less ------ $4732 --'-'-'— ---------------------- 1,00115.000.._._.._ $144.68–._'>.""""."'__________.__ 5,001 �010,000 ---- $338.6d -----_.. 10,001 l0 50,000 ---- 5531.01 ---�------------- 50,001 to 100,000 — $769.56 ----, – �nn nn� ,,.,.,�,o ""' ¢� oa� an ___ ..______-______ SERVICE CHARGE Spxial Handling Fee --- $47.32 Revision to Notif�calion --- $47.32 ReWmed Check Fre --- $25.00 Planned Renovation ---- $531.01 Praedure 4 or 5 Plan — E531.07 ivivm ATTEN710N: Keep a[Opy of you! Rotificati0n. Sute law reQuires �a� you prwitle a copY of Ne aemotition no�i6cation m Builaing ana Safety Eelore issuance ol a tlemolilion permit. For questions call 90939&273fi. Please mail the form and lee to AOMD. Mailing saves lime, money antl retluces trattic antl air pollulion. MAIL FORM AND FEE T0: SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074�5641 paga 2 ol2 TELEPHONE :(909) 796�2336 FAX :(909) 39fi-3342 Fortn REV 20030fi2] FORMS, INSTRUCTIONS, AND THE RULE 1403 CAN BE OBTAINE� FROM AOMD WEB SITE AT HTTP://W W W.AQMD.GOV c^ ��MD is located at 21865 E. Copley Drive, Diamond Bar, CA 91765-0182 (909) 396-2000 CITY OF COSTA MESA BUILDING D►VISION F � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Faz (714) 754-4856 • www.ci.costa-mesa.ca. 07-00025 �. FOR INSPECTIONS CALL: (714) 754-5626 ��. GRADING PERMIT JobAddress: 885 JUNIPERO DR Status: �SSUED Suite: Applied: OB/08/2007 Vicinity: ANGELSPLAYGROUNDATTEWINKLEPARK-� � - , � Issued: Ot/07/2008 Parcel Nunmber. 14134243 � � Zoning: � � o,pp�icant: GUSTAVO ZAZUETTA Address. Phone: 714-3253268 Zip: Owner. CITY OF COS7A MESA Address P 0 BOX 7200_ � ,_ � _ .. �Phone: � COSTA MESA, Cq � . � Zip; 92628� Contracror: ;MICON CONSTRUCTION INC Address: 1616 SIERRA MAbRE - - ' � � � �" � �- � � - � Phone: 714-666-0203 PLACENTIA; CA, , , Zip: 92870 � „ .. - Licertse:�..744198.' � " . . _ . :.. . .... _ . :: Eng : Address: �� - . - � Zip: CUBIC YARDS 210CY FILL THE FOLLOWING REQUIRE A SEPARATE PERMIT 1- LIGHT POLES 2-SEWER CONNECTION 3- TRASH ENCLOSRE 350 Phone: License: 0 FEE SUMMARY Plan Check: $33.00 Calc Valuation: aoo,000.00 $0.00 Permit: $0.00 NOTICE: Thd�b9Tauthorized b$@�(30permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 1��1�2) EXPIRATI(ffi�DE�N1�T EXPIRES$CB.mDAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the ��Sdd�thbrized under this permit to be considered legal, such work must compty with all applicable codes, and all required inspections and fnal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. cooeM.T�s�inoxme $0.00 DRTE ixnnn�s cooek INSPEG710NTYPE DATE ixnnn�s 161fi "' _' `�_•-- � - ^ enNen �� F' al Mashan' a! izss PoolSpaFinal �LANNIN G�ZO�1�N��mb�9 200 N�Root 210 Final Eiecirical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Fac�ory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site �� 0 � 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby aKrm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate o( consent to self-Insure for workers' compensation, as provitled for by section 3700 of the labor Cotle, for the peAormance of ihe woik for which this permit is issuetl. ��— I have and will maintain workers' compensation insurance, as required by secfan 3700 of the Labor Code, for the perfortnance of ihe work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: [Czrrier..- � 1�¢t�'`Q"�e 01- I�Z�,P ( �L O(15 (This sectbn need, nrot be mmpleted il the peimrt rs valuetl al one huntlretl dollars (8100) or less ) Policy Number: `-f' ��-S - � � � � ❑ I certif t 1 in [he perfo nce of the work for which this pertnit is issued, I s all ot employ any p on in any manner so as to become subject to Ihe ' compensation ws of California, and agree that if I should become u ct lo ihe vrorkef5' compensation provisions of Seclion 3700 0� ihe La r dde, I shall forth th comply with these provisions. � d _ � `� � � �fS� � ' . Appl�ta ' ignaWre L_._Oale- " WARNING FAILU&E TO SECURE WORKERS' COMPENSATION COVER4GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrm that I am licensed under provisions of Chapter 9(commencing with Section 7000) of Division 3 o the Business and Prolessions Code, and my lice e is full torce and efte . � '%/�/�f//�� c 55a /a -�3 a � %-� f"' -_ �- " ConVac s ignaWre L,Dale _ ' i�- CONSTRUCTION ENDING AGENCY: ❑ I hereby a�rtn that there is a wnstruction lending agency for the peAormance of the work fa which [his pertni[ is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Atldress: OWNER-BUILDER DECLARATIONS: I hereby aKrtn that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sea 7031.5, Business and Professions Code: Any city or county which requires a permi[ to conslruct, alter, improve, demolish, or repair any slructure, pnor to its issuance, also requires Ihe applican[ for such permit to fle a signed statement that he or she is licensed pursuant to the provisions of lhe Conlractors License Law (Chapter 9(commencing with Section 7000) of Division 3 of the Business and Pro(essions Code) or that he or she is exempt [herefrom antl Ihe basis (or the allegetl exemption. Any violation o( Section 7031.5 by any applicant for a permit subjects the applicaM to a civil penalty of not more than five huntlretl tlollars ($500).): ❑ I, as ovmer of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and lhe slruc[ure is not intended or offered for sale (Sec. 7044, Business and Professions Cotle: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such vrork himself or herself or throuqh his or her own employees, provided that such impmvements are not inlended or oRered for sale. If, however, the builtling or improvement is soltl within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am E%CLUSIVELY CONTRAC7ING WITH LICENSED CONTRACTORS to construct Ihe pmject (Sec. 7044, Business and Pro(essions Code: The contractors License Law dces not apply to an owner of property who builds or improves thereon, and who cont2cts for such project �+nth a contracta(s) license pursuant ro the Cont2ctors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Ovmer ID venfied by driver's lice, .❑ Yes ❑ No Driver's License No. Expires: Venfication ot Ownership by (rype ot document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby cert'rfy that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connec[ion with wvrk authonzetl by this permit, and that no building strucWre, scaf(dding, false�wrk, or tlemolition or tlismantling thereof, vnll be more Ihan Ihirty-six (36) (eel high. (Chap. 32, Grp 2, Art 2, Sec. 341, TOe 8, Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a pertnit to do such work from the division. Applicanfs Signalure Division of Induslrial Safery Pertnit Number. _ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicaM or present or future builtling occupant need to fle and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of Ihe Califomia Health and Safery Code requires, with some excep�ions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o( hazardous ma[erials equal ro or greater lhan a weight of 500 pountls, or a volume of 55 gallons, or 200 cubic feet of compressed gas at slantlartl temperature and pressure). 2. Does or will the applican[ or present or future builtling occupant need to (le a regisiration form for acu[ely hazartlous materials? ❑ Yes ❑ No (Section 25533 0( �he California Healih and Safety Code, with some exceptions, requires registration vnth Ihe Costa Mesa Fire Departmen[ by each business which at any one lime has on hantl a quanti[y of acutely hazardous matenals equal [o or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic fee� of compressed gas a� standard temperature antl pressure). 3. Does or will the applicant or present or fuWre building ocwpant need to prepare an RMPP (Risk ManagemeM antl Prevenlion Program for acutely hazardous malerials)? ❑ Yes ❑ No (Sec[ion 25534 of the Califomia Heal[h and Safery Code provides iha[ the Costa Mesa Fire Department may require �he preparatioq certification antl filing with the Fire Department of an RMPP by businesses which are requiretl to regis[er acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the Califomia Health and Safely Code been fully complietl with? ❑ Yes ❑ No 5. Does or will Ihe applicant or present or future building occupant require for the wOrk which is the subject of this application a permit for such wnstruction or modifcation from the South Coast Air Quality Management District or from any other air pollution control distnct or agency? ❑ Yes ❑ No (Section 65850.2 of the Cal'rfomia Govemment Cotle requires that the requested information be fumished on applications fa non-residential builtling permits). 6. Will any part of Ihe facility to be construcletl untler this permit be within 1000 feet from the outer boundaries o( a school? ❑ Ves ❑ No (If "yes", lhe facility must meet [he requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit fmm the South Coas[ Air Qualiry Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Salety Code Section 42303 been made? ❑ Ves ❑ No 8. (If'yes", atlach certificate of compliance from the appmpnate air polWtion control offcer). CERTIFICATE OF COMPLIANCE: I certify thal under penalry of peryury the information given above is correct I agree to comply with all state laws and ci[y ordinances regarding Hazardous Materials and Emissions. CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: i certi(y under penalty of perjury Iha� I have read Ihis application and state that the information given is correct I agree b comply vnth all state laws and city ordinances relati�U � building consWction, antl authorize represen[a�ives of ihe Ciry of Cq6ta �lesa to enter�on the above-descnbed property for in5pection purpb4e� I agree not ro o upy or allow occupancy of any building authorizetl by (hi8bertnit until final i ection. SignaWre Date //��, ��v /-� 7 �� 309�46(3/01) i. --qnalorAmhorizetl p icanl / Date '- � O f o � > J � �m�m �+'• PERMIT TYPE 1 - � � + � CITY OF COSTA MESA BUILDING DIVISION "' ' "�' 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-0856 • �wiw.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER. E07-00942 ELEC STATUS: ISSUED DATE ISSUED: 1 2/1 312 0 0 7 ISSUED BY: BJK JOB ADDRESS: 885 JUNIPERO DR CM SuitelUnit: Vicinity: ANGELS PLAYGROUND= SCOPE OF WORK: i TEMPOR4RY POWER IN CONJUNC7101J WITH THE CONSTRUCTION OF A 889SF MEM'S/ WOMEN'S/UNISEX RESTROOM BLDG WITH A STORAGE�ROOM"AT "ANGELS PLAYGROUND" AT TEWINKLE�PARK. REF'.�Ci/-00164 ��7� OWNER: CITY OF COSTA MESA �.. PHONE: APPLICANT: GUS 7AZUETTA PHONE: 714-666-0203 � CONTRACTOR: MICON CONSTRUCTION WC Address: 1816 SIERRA MADREUnit City/State: PIACENTIA, CA � ZipCode: 92870 ELECTRICAL pERMIT FEES Electrical Plan Check Fee: $0.00 Electrical Permit Fee: $0.00 Reinspection Fee $0.00' TOTAL FEES $0.00 Address: P O BOX 1200 Unit: City/State/Zip: COSTA MESA, CA Address: 7616 SIERRA MADRE Unit: City/State/zZip: PLACENTIA, CA 0 License No. 744198 PHONE: 714-666-0203 CELL: ,�,.ir�isez NOTICE: The work authonzed by this pertnit shall comply with all applicable, handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § t, 1241-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM �ATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In ortler for the work auihorized under this pertnit to be consideretl legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obWin inspeclions and final approval will result in the expiration of,this;permit. 0/. INSPECTIONTYPE OAiE INPTIALS COOE� INSYECTIONIYPE UAIE IN7IML 1818 Fized System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 20B Final Plumbing �,(�� Z00 Final Re-Rool 27p Final Eleclncal %QjLp ,` Q% ��(j///k.}t,(j 201 Final BIocWRe�aining Wall 212 Final Fire Preven�ion T—C1 202 Final Factory Fire place 220 Final Planning Appmval 203 Final Sign 222 Final Site �� 204 Final Demolition - 250 Final Building/Occupanty t 1 WORKERS' COMPENSATION DECLARATION:� I hereby affirtn untler penalry of perjury one of the (ollovnng Ceclarations: ❑ I have and will maintain a certificate of consen� to self-Insure for wvrkers' compensation, as providetl for by seclion 3700 of Ihe Labor Code, for the performance of the work for which Ihis permit is issued. I have and will maintain workers' compensa[ion insu2nce, as required by s tion 3700 of the Labor Code, for ihe peAormance o( the v.ork fw which this pertnit is issued. My workers' wmpensation Insurance carrier antl policy numberare:�� n / ��50��^'�� Carriec G e��-A� � Policy Number. � � n l � ❑ I certify that in Ihe peAormance of the work for which this permit is issued, I sh Q no mploy any perso in any manner so as to become subject b the wor �rs'; ompensation law of Califomia, and agree that if I should become je t to lhe worker5' mpensation provisions o( Section 3700 of the Co e, I shall fo wit omply with these provisions. '� iz-�3- o �� Aodionf i Wre Date WARNING: FAILUR TO SECURE WORKERS' COMPENSATION COVERAGE IS UNIAWFUL A D SHALL SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLL4RS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrm Ihat I am licensed under provisions of Chapter 9(commencing wilh Section 7000) of Division 3 of the Business and Protessions Code. and my licens,e is in full force and effecl Lia � f'- � Class # � i�o �l''!,?j'07 Contr� or' ignature � Da�e CONSTRUCTI L NDING AGENCY: ❑ I hereby aKrtn thal there is a constmctbn lentling agency for Ihe peAortnance ol the v.ork fa which this pertnit is issued. (Sec. 3097. Gvil Co[le). Lender's Name: Lender's Address: SipnaWre Dale OWNER-BUILDER DECLARATIONS: I hereby affirm Ihat under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW lor the following reason (Sec. 7031.5, Business antl Professions Cotle: Any city or county which requires a permil to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such pertnit to fle a signed statement that he or she is licensed pursuant lo the pmvisions of lhe Contractors License Law (Chapter 9(commencing with Section 7000) o� Division 3 of the Business antl Professions Cotle) or that he or she is eaempt therefrom antl the basis (or the alleged exemption. Any violation of Section 703L5 by any applicant for a permit subjects the applicant to a civil penalty of not more Ihan five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the s[ructure is not intended or oRered for sale (Sec. 7044, Business and Professions Code: The Conlrectors License Law does not apply to an owner o( property who builds or improves lhereon, and who does such vrork himself or herself or through his or her own employees, provided ihat such improvaments are not intended or offered for sale. I(, however, ihe building or improvement is sold vnthin one year of completion, the owner-builder will have the burden of proving that he or she did not builtl or improve for purpose of sale.). ❑ I, as ovmer of the property, am EXCLUSIVELY CON7RACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Pro�essbns Code: The contractors License Law dces not apply to an ovmer of property who builds or improves Ihereon, and who contracls fa such prqecl with a cmiracta(s) license pureuant to the Contractors License Lav.s.). ❑ I am exempt under sec. Business and Professions Code for this reason: Sipnawre 905P46�10]) Owner ID verified by drive� 0 Yes ❑ No' Dnver's License No. Expires: Verification ol Ownership by (rype of documenl, i.e. - propeny tax bill or deetl): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify lhat no excavation (rve (5) or more teet m depth into which a is requiretl lo tlescend, will be made in connecl'qn vrith work autMrized 't, and ihat no building strucWre, scaftdding, falsework, or demolilion or tlisman ling thereof, will be more than thiAy-six (36) feel high. (Chap. 32, Grp 2. M 2, Sec. 347, Ttle 8, Cali(omia Administrative Code). ❑ As owner-builder, I vrill not employ anyone to do vrork which would require a permit from the Division of Industnal Safety, as noted above. unless such person has a pertnit to do such vrork from Ihe division. Appliranfs Signalure oale Division of Industrial Safely Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: t. Will the appliwnt or present or fuWre building occupant need to file antl certify a Business Plan tor emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safery Code requires, with some exceptions, that a Business Plan be filed with lhe CosU Mesa Fire Depanment by every business vmich has at any one time dunng a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressetl gas at slandard temperature and pressure). 2. Does or will the applicant or present or future builtlinq occupant neetl to file a registration form for acutely hazardous materials7 ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safery Code, vrith some exceptions, requires registration with Ihe Costa Mesa Fire Department 6y each business which at any one time has on hand a quantiry ot acutely hazardous materials equal lo or greater than a weight ot 500 pounds, or a volume of 55 gallons, or 200 cubic (eet o( compressetl gas al standard temperalure and pressure). 3. Does or will the applicant or presen[ or future building occupan� need to prepare an RMPP (Risk Management and Prevention Program for aculely hazartlous materials�? ❑ Yes ❑ No (Section 25534 of ihe Califomia Health and Safery Code provides that the Costa Mesa Fire Department may require ihe preparation, cenifwtion and Ning with the Fire Department of an RMPP by businesses vfiich are required b register acutely hazardous ma�erials with lhe Fire Department. 4. If an RMPP is presently required, has Section 25534 of the Califomia Heallh and Salety Code been (ully wmplied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is Ihe subject of Ihis appliw�ion a pertnit (or such consWction or modification (rom the South Coast Air Quality Management DisUict or from any other air pollution coniml disMct or agency7 ❑ Yes ❑ No (Section 658502 ot the Califomia Govemment Code requires that the requested infortnation De fumishetl on applications fa non-resitlential buildirg permits). 6. Will any part o( Ihe (acility to be consWcted under this permit be within 1000 (eet from the outer boundaries of a school? ❑ Yes ❑ No Qf "yes", the facility must meet the requiremenl of Seclions 25534 and 42303 of the California Heal[h and Safery Code). 7. If a permit fmm the South Coast Air Quality Management DisMcl or other air pollution control tlistricl or agency is required for the vrork which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Sa(ety Code Section 42303 been matle? ❑ Yes ❑ No B. Qf "yes", attach certi�cate ot compliance from the appropriate air pollution control o�cer�. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the inlortnation given above is correct I agree lo comply with all state lavrs and ciry ordinances regartling Hazartlous Materials and Emissions. Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRV: I certify under penalty of perjury that I have read this application antl state that the infortnation given is wrtect I agree to compty with all state laws and city ordinances relating ro building wnstruction, and authorize representatives of the Ciry of CPsta Mesa to enter upon the above�escribed property for inspection p ose9. I agree not ro occupy or allow occupancy of any building authorized b this ermit until �nal insp clion. Sie� mreolLe eqs) Date ' � �2-/3'� 7 AntllwAut�an E pLanl Dale