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HomeMy WebLinkAbout170 MERRILL PL - Building Permits `pStwMFs9 CITY OF COSTA MESA 4 `9 P.O.BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 92628-1200 = ;: t' = F.A1Y I i a DEVELOPMENT SERVICES DEPARTMENT a •yeeAPe4F1Ee AS August 1 , 004 To: • Building Safety Division AT&T Broadband Code Enforcement Newport-Mesa Unified School. Communications Dist.(2) County Clerk Pacific Bell County Planning and Dev. Services Police Dept. - Planning & Research County Registrar of Voters Sanitary District Engineer County Tax Assessor Sanitation Division Office Engineering Division (2) So California Edison Company ESRI Southern California Gas Fire Admin. - Training Officer State Board of Equalization Fire Admin. - Mark Brown (Station 6) U. S. Post Office - AIS Fire Prevention U. S. Post Office, Adams Irvine Ranch Water District Thomas Brothers • Mesa Consolidated Water District File (2) The City of Costa Mesa would like to inform you of the following address change: OLD ADDRESS NEW ADDRESSES A. P. NOS 168 Merrill Place 168 Merrill Place 426-132-17 172 Merrill Place 170 Merrill Place 426-132-18 176 Merrill Place 172 Merrill Place 426-132-19 174 Merrill Place 176 Merrill Place Your cooperation in this matter is appreciated. Sincerely, MEL LEE, AICP Associate Planner Attachment cc: Kimberly Brandt, Senior Planner Patriot Development Company 3111 North Tustin Avenue, Suite 220 Orange, CA 92865 Building Division(714)754-5273 • Code Enforcement(714)754-5623 • Planning Division(714)754-5245 FAX(714)754-4656 • TDD(714)754-5244 • www.ci.costa-mesa.ca.us 05111MF CITY OF COSTA MESA , 4�i BUILDING DIVISION >:j r -sr DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER �: i� PERMIT / �r '/E05-01179 itberonano`i(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa€L TRICAL PERMIT 77 FAIR DRIVE,COSTAyYMESA,CA 92626 Ec Job Address: 170 MERRILL PL Status: ISSUED Suite No Applied: 11/08/2005 Vicinity: Issued: 05/08/2006 Parcel Nunmber: 42613218 Applicant: GABE C Address: 3111 N TUSTIN STIN AV AV .� STE 220 Phone: 714-974-5111 ISSUED BY: ORANGE,CA Zip 92865 Owner: LISSOY FAMILY TRUST Address 2518 N.SANTIAGO BLVD. Phone: 714.974.5111 ORANGE,CA Zip: 92861 Contractor: PATRIOT DEVELOPMENT COMPANY Address: 3111 N TUSTIN AV STE 220 Phone: 714-974-5111 ORANGE,CA Zip: 92865 License:819723 • SCOPE OF PERMIT NEW 2486 SF TWO-STORY SFD(1201 SF 1ST FLR AND 1285 SF 2ND FLR)W/461 SF ATTACHED GARAGE AND 65 SF PORCH. REF.:604-01926"PLAN 2"(4 BEDROOM,3.5 BATH) ELECTRICAL TO INCLUDE:2,486 S.F.S.F.D.,1 LIGHT FIXTURE, 1 OUTLET AND 1 SWITCH IN THE GARAGE. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 - . - Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $139.22 2486 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa _ $0.00 0 up to 10 kva/kw $0.00 0• Lighting Fixts $1.10 1 up to 50 kva/kw $0.00 0 Recept Outlets . $1.10 1 up to 100 kva/kw $0.00 0 Switches $1.10 1 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 • Res Appl $0.00 . 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 , 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a • $0.00 . 0 , Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp - $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $166.02 Intermed Pole $0.00 0 COMMENTS /SPECIAL CONDITIONS . NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-2B,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 .-- 2446-46(6/00) \/ WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ' ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. ❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is leciled. My workers'compensation Insurance carrier and policy number are: _ Cartier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,an gree at if should become subject to the workers'compensation provisions of Section 3700 of the LaborJCode,I shall forthwith comply with theses r Isio s.4 gree /�i' / � r..(0 Applicant Signature:/,I�� �r^^�— l t%r7 r�"' Date: �(/ D WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES A D CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licen n r �Jls of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Proles ions Code,and my license is in full force and effect.Lic.# /�7//�/ Class# /� —�P'//$. Contractor's Signature: ,av,L� d��,.) Date: _Tl b! 0 (p CONSTRUCTION LENDING AGENCY: / ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,CMI Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation.WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIV&LY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)of more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health end Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes 0 N (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 It an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency? Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constmcted under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Calitomia Health and Safety Code). 7 If a permit from the South Coast Air Duality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. . Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signa yr Of Le., Ow :r(s) D to An. •r Authoriz:.App scant Dat • CODE It 'INSPECTION TYPE • PALE ' Ilfim&LS -CODE I 'INSPECTION TYPE PATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing r 200 Final Re-Roof 210 Final Electrical 011 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy s CITY OF COSTA RAESA , 4t. , BUILDING DIVISION >ii:i,.. , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT ' /04-01926 e4 V (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.BUU_DING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 170 MERRILL PL Status: ISSUED Suite: Applied: 11/122004 Vicinity: Issued: 12/022005 Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N Parcel Number: 42613218 Zoning: Applicant: HUAPAYA, YOLANDA (-, p I ��� Address: .._ - /t Pli1 . ,' Phone:, .714.393-6251 ISSUED BY: Zip: - Owner: LISSOY.FAMILY,TRUST ' - Address 2518 N:SANTIAGO BLVD.- 1/4,_'_ .. 714.974.5111 '- \ ORANGE,CA ` ' c ".:-.1"--.: _ :-ZiP. ,,,,92861..,......r.,_- '.. ' _ Contractor: PATRIOT'DEVELOPMENT COMPANY �: / \\"1-`k , Address: 3111 N.TUSTIN AVE:�STE 220 �` iA,,v -. * Phone: 714-974-5111 ORANGE,CA 7 Zip:.- -92865. License: 819723 .Arch . Eng:Eng: , Address: - - ' Address: Phone: - - — --�-: - Phone: -. Zip: . ' License: - - - - %� - License: - SCOPE OF PERMIT • - NEW 2486SF TWO-STORY SFD(1201'SF 1ST FLR AND 1285 SF 2ND FLR)W/461 SF ATTACHED GARAGE AND 65 SF PORCH: " "PLAN 2"(4 BEDROOM,3.5 BATH) - - _ ' / - - - REF;PA-03-33,T-16560,G04-00014 - '� \" - S . - _ - - - - FEE SUMMARY -7,1_ Plan Check:. i $1,162.82 - • -, Calc Valuation: 'x241, 956.50 `\ Permit: •' $1,788.95 - - ('. -- = Claim Valuation: $0.00 •:SMTP Res: $24.20 .. ' SMII? Corn: •$0.00 ,-/-.' :_7 Other:., • . $0.00 r - // ,In§pection:y $0.00 ' ;-,� Total: $2,975.97 .- . , , ` , PLANNING 8 ZONING' SETBACKS'• ) -,.'-,i--..- . MAIN STRUCTURE Front 22=0 - 'Rear 10-0 ^ Left - .' 50- - �j Right " 5-,04 /-' ACCESSORY -Front 0=0� i • Rear -0-0 '' ' _ Left - 0-0=- 'Right 0-0%, ,/,/,'; ,_ . r. , ^- , , __ --- PARKING EXistin q. ,A0 Required-'- ,4 Proposed: 4: -;- j •- NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codean s; d all required Inspections and final approval must be obtained.Failure to obtain inspections and jpal.,gpproval.will.resull in the expiration Permit. FOR INSPECTIONS CALL: (714)754-5626 2446-48(WOO) DECLARATIONS WORKERS'COMPENSATION DECLARATION: • I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. - C i❑=I:bave and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier • Tru"'Policy.Number: �ZTtrls clion need not ad if the permit is valued et one hundred dollars($100)or less.) ❑ I Certify that in the performance of the wo fbrwhich.lhis,permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should 6`ebOme-sub)ect10 the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with t ase provisions. (Applicant Signature: Date. `1NARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL'a I ES AND CML RNES UP TO ONE HUNDRED THOUSAND DOLLARE(S103,0001 IN ADDfON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37080F THE LABOR CODE, •• :EST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I herirm.that.l.am kens u eh luovj�ons of Chapter 9(commencing with Section 7000)of Division 3„ ,1,e Business and Professions Code,and my license Is in full force and eftectt,11 ! GYM `claioE. wee= Ignaw : f!et at 1 Z/ t/fr- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that t am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of properly who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,I.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person is required to descend,will be made In connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). o 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit lar such construction or modification from the South Coast Air Quality Management District or Irom any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will anyfacilitypermit— __..____.._.._._.._..._ part of the to be constructed under this be within 1000 feet from the outer boundaries of a school? 0Ves 0 No (If"yes•••the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject Of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 44, Sig re %Lee9vner(s) /�D/ale r fgA°&.7A Va zed Applicant CODEC P4SPECTION TYPE PATE f INSPECTION TYPE PAIS MALS 1616 Fixed System Final Fire Prevention • 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof• ' ' . 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place • - ' 220 Final Planning Approval • 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy S Gam/ NEWPORT-MESA UNIFIED SCHOOL DISTRICT Ng 5657 CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: (\I) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ,� j ( ) County of Orange Plan Check No./ay-© A, Applicant: AK ?)eviou Address: /✓( ��J ? l( L N 44 ./ t* . lel) Telephone Number:/ ' (7/CO U i 7W.5 II 1 Tract/Parcel and Lot Number(s): �� (� Location of Project: k ° ' QiC d Number of Square Feet of: 2/ f L( Residential Space 014 S x 61.84 Total -I) 5 /9 Commercial and Industrial Space x 6 .30 Total CommerciaUlndustrial Project is: (Check One) Warehouse _ Motel _ Preschool R 8 D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage RacquetMealth _ Large Office Heavy Industrial _ Hotel _ Office Bldg. __ Regional Shops _ Medical Office _ Restaurant Light Industrial _ Office Park _ Fast Food This project is exempt because This certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: t Authorized Representative The above representation as to square footage is true. Applicant agrees that if it is later determined that such representations are not true,then this certificate shall automatically terminate and the appropriate City/Countyy�shhall be notified. IYADateK L 7 J 6 ) c7 Mild7 / Applicant AUG 08 2007 4 : 43 PM FR TO 917149745091 P . 03 Aug; 8. 2007 3: 19PM Pinot Development Company No. 9315 P. 3 INSULATION CERTIFICATE IC-1 Stte Address • Permit Number 170 MercirAk PMce GoS "ns5,I • blumberand Street City - 6444(, County Subdivision Lot Number Description of Installation 1. ROOF Material Brand Name Thickness(inches) Thermal Resistance(R-Value) 2. CEILING Batt or Blanket Type 'SITh _ Brand Name CEn.1437ZED Thickness(inches) se) Thermal Resistance(R-Value) '20 Loose Fill Type Brand Contractor's min installed weight/ft'_lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance(k-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material `P 'rc5. Brand Name Thickness(inches) .s Thermal Resistance(R-Value) $. Exterior Foam Sheathing Material Brand Name Thickness(inches) Thermal Resistance(R-Value) 4. RAISED FLOOR Material Brand Name Thickness(inches) Thermal Resistance(R-Value) S. SLAB FLOOR/PERIMETER Material Brand Name Thickness(inches) Thermal Resistance(R-Value) Perimeter Insulation Depth(inches) 6. FOUNDATION WALL Material Brand Name Thickness(inches) Thermal Resistance(R-Value) Declaration t hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Standards for residential buildings(Tide 24.Part 6,California Code of Regulations)as indicated on the Certificate of Compliance,w e appy 1 • - (tem#s ignatur , at Installingg,bVnaacto(Cot Nae)OR General Contractor(Co.Name)OR Owner Dem#s Signature,Dara Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner (tem its Signature,Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner JUL 19 2007 2 : 00 PM FR 10 919492241963 P . 05 tOWaildesign Incorporated DRYWALL • INSULATION ' PAINT• PLASTER* CONTRACTOR 0 Costa Mesa Street Address City Orange Patriot Development Merill Place 4 County Builder Project Lot Description of Insulation : Thickness R-Value Exterior Walls insulation Type: Batts 31/2 13 Flat Ceilings • Insulation Type: Batts 10 30 Cathedral Ceilings Insulation Type: Batts 0 Garage Ceilings Insulation Type: Batts 6 1/4 19 Interior Walls Insulation Type: Batts _ 0 Interni Ceilings Insulation Type: Batts 0 Garage Walls Insulation Type: Batts 0 Slab on Grade Insulation Type: Batts 0 Blown Ceilings Insulation Type: Cellulose 0 Blown Ceilings Insulation Type: Insulsafe 0 Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficient Standards for residential buildings(Tide 24,Part 6,California Code of Regulations) as indicated on the Certificate of Compliance,where applicable. *• "" :°"I tq ' 449739 L%Jf) .• Walldesign,Inc. License Number Signature Data Insulation Subcontractor RECEIVED TIME JUL. 19. 1 : 59PM 4` MF CITY OF COSTA MESA BUILDING DIVISION I> ..4r DEVELOPMENT SERVICES DEPARTMENT P MIT NUMBER f 1 _14wrr I PERMIT 05-00641 'Karo ,tie (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 170 MERRILL PL Status: ISSUED Suite No Applied: 11/08/2005 Issued: 05/08/2006 Vicinity: Parcel Number: 42613218 ISSUED BY: Applicant: GABE CEDILLO Address: 3111 N TUSTIN AV STE 220 Phone: 714-974-5111 ORANGE,CA Zip: 92865 Owner: LISSOY FAMILY TRUST Address: 2518 N.SANTIAGO BLVD. " Phone: 714.974.5111 ORANGE,CA Zip: 92861 Contractor: PATRIOT DEVELOPMENT COMPANY Address: 3111 N TUSTIN AV STE 220 Phone: 714-974-5111 ORANGE,CA Zip: 92865 License:819723 SCOPE OF PERMIT NEW 2486 SF TWO-STORY SFD(1201 SF 1ST FLR AND 1285 SF 2ND FLR)W/461 SF ATTACHED GARAGE AND 65 SF PORCH. REF.: B04-01926"PLAN 2"(4 BEDROOM,3.5 BATH) MECHANICAL TO INCLUDE: 1 FAU<100K BTU, 1 REPAIR/ALT COOLING/HEATING, 1 FACTORY FIREPLACE;1 HOOD W/MECH EXHAUST, 1 VENT FAN,AND 1 COMPRESSOR/ABSORPTION SYSTEM 3 TO 15 HP. FEE SUMMARY • Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $14.80 1 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $13.70 1 Evaporative Cooler $0.00 0 Inst/Rep.Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0 Factory Fireplace $10.65 1 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust $10.65 1 15 To 30 hp/1,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00 0 Vent Fan/Single Duct '$7.25 '1 Over 50 hp/Over 1,750 BTU $0.00 0 Appliance $0.00 '0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $27.15 1 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace . $0.00 0 Other Mechanical Fee Floor or Suspend Heater • $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $107.70 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. " INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes,rend.all required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiration of thi er IC FOR INSPECTIONS CALL: (714)754-5626 2446-46(6/00) r • , WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ' • ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. My workers'compensation Insurance carrier and policy number are: Carrier: - Policy Number: (This s ' need not be completed/f the permit is valued at one hundred dollars($100)or less.) I certify that in the performance of the wo for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C Ilfornie,and a et t it I hould become subject to the workers'compensation provisions of Section 00 of the Labor Code,I shall forthwith comply with these pr ons. ���/� Applicant Signature:, ( (/pli Date:57 6 l Q WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL P TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5108000),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 affirm that I am licensed u, r o�/y's�ion&,pjChapter 9(commencing with Section 7000)of Division 3 of the Business a rofessions Code,and my license Is in full force and effect.Lic.# 'G� �j Class 4 / —tet/ Contractors Signature: � P aria, Date: .S/�/O& CONSTRUCTION LENDING AGENCY: t ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,end who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business end Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ l am exempt under sec. _ Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑Yes ❑No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 9 I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the Califomia Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application appermit for such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency? ID Yes LJ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑No (If'yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Duality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health end Safety Code Section 42303 been made? 0 Yes ❑No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances • regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. e/t,ignature 1LyaQw r(s) Date L ,( pl, r�/V/ l . And/Or Arifedpplicant Date CODE f INSPECTION TYPE PATE 1NTIMLE pH INSPECTION TYPE J Q g �� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1" 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof ' 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition - 250 Final Building/Occupancy CITY OF COSTA MESA BUILDING DIVISION F r._, 41 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER J PERMIT 7P05-00845 A. (714)754-5273 • Fax(714)754-4856 • www.cl,costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 170 MERRILL PL Status: ISSUED Suite No Applied: 11/08/2005 Issued: 12/05/2005 Vicinity: Parcel Nunmber: 42613218 Applicant: GABE CEDILLO ISSUED BY: Address: 3111 N TUSTIN AV STE 220 Phone: -714-97415111 - ORANGE,CA _ Zip:: 92865 , Owner: LISSOY FAMILY TRUST Address 2518 N:SANTIAGO BLVD _ -'-�^ +- =c'-'�-'-^^''^^ - Phone: 714.974:5111 -• .. - . ORANGE,CA Zip: 92861 Contractor: PATRIOT DEVELOPMENT COMPANY Address: 3111 N TUSTIN AV ' STE 220 Phone: ' 714-974-5111 - • .z 'ORANGE,CA Zip: 92665 , License:,.'.819723.;.-.-• ,. t - - ,_„ ._ _ • ' SCOPE OF PERMIT NEW 2486 SF TWO-STORY SFD(1201 SF 1ST FLR AND 1285 SF 2ND FLR)W/461 SF ATTACHED: GARAGE AND 65 SF PORCH. '` ' 'REF.:B04-01926-PLAN 2"(4 BEDROOM,3.5 BATH); , ._ „ : ' 4, PLUMBING TO INCLUDE:2 BATHTUBS;'1`DISHWASHER 1 GAS SERVICE, 1 LAUNDRY TUB/WASHER, . '.!;1:LANDSCAPE IRRIGATION;.5.P-TRAPS,1 PRESSURE REGULATOR4,1'SEWER CONNECTION,2. :/SHOWERS, 1 KITCHEN SINK, 1 WASH BASIN, 1 WASH BASIN SET;:3 WATER-CLOSETS, 1 WATER ' HEATER AND 1 WATER SERVICE. - -- FEE SUMMARY' " AMT QTY AMT QTY AMT QTY ISSUE FEE ' ,$23.50 Laundry Tub/Washer '$9.80 1 . Sump Pump - $0.00 0 Backflow irrigation - $0.00 0 Landscape Irrigation -.-$14.80 _ 1 'Swimming Pool $0.00 0 Backflow Preventer ., ' $0:00 ' 0 , P-Trap $49.00 5 Trap Primer ^ $0.00 0 Bathtub . $19.60 2• Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System ' ' $0.00 0 ' Process Piping(per 10 ft) : $0.00 0 Vacuum Brkr Bkflow(1-4) ' $0.00 0 Connect(Ice,Soda,etc) : $0.00 . ,.0 Receptors $0.00 „-0 Vacuum Brkr Bkflow(5+). $0.00 0 Dental Units $0.00 0 Septic Tank ' $0.00 " ` 0 Wash Basin' $9.80 1 Dishwasher $9.80 “1 ' ',!Sewer Cap for Demo,.:3/4"..-40.00-4-0 • ,-47•-Wash Basin Set ~ $9.80 1 Drain,Floor $0.00' 0 ' Sewer Connect" ,"'$24.65 . '1 ' Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain,Roof -\$0.00 0 • ' . Shower . $19.60.. 4- Water Heater l vent $12.30 1 Drinking Fountain - - 50.00- 0 . Sink-,bar ' r, $0.00, •_0' ' Water Piping(Inst or Rep.) $0.00 0 Expansion Tank =-$0,00 ' Oz--, , Sink,commercial :$0.000 "- 0 ...'`'Water Re-pipe' $0.00 0 Gas Earthquake Valve $0.00 0 ' , Sink,Floor $0.00 .. 0 . • Water Service $9.80 1 Gas(1-4 outlets) $0.00 - 0 . Sink,kitchen_, $9.80 ',' 1'- ' ' " Water Softener $0.00 0 Gas(Over 4 outlets) $0.00 '0 'Sink,service/mop .- -.1 ,513.00„;;"; 0;',' . OTHER 50.00 Gas Repipe $0.00 0- Spa(private)' 11-- $0.00 0 .::-.VIOLATION $0.00 Gas Service $9.80 1 ' ' '=-Spa(public) $0.00 0 -"- PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 '• - TOTAL CALCULATED FEES: $271.25 COMMENTS/ SPECIAL CONDITIONS • - -77="65; 4 .- ' --' u., NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92.28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended--P. ned fora period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all ap ' le codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the at on of this permit. FOR INSPECTIONS CALL: (714)754-5626 TtS,u;.,4.:_:ap mcnrn -4 - 244646(6/O6) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,a• •rovided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier end policy number are: Carrier: Policy Number: (This section need not be completed i/the permit is valued at one hundred dollars($100)or less.) rot'certif1that in the performance of the work for which this permit is issued, shell not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shell forthwith comply with these provisions. A••I Ca ktOSlgneture:— -- 144,1 ' WARNING'. TO SECURE WORKERS'COMPENSATION ODVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPL'OYERtTO CRRJ$aNAJ PENALTIES AND CML FINES UP TO ONE HUNDRED D DOLLARE(5100,000),IN ADD1ON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE.INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed und'r•rovisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and of ssions Code,and my license is in full fnd[effecUlli.q. Glass It' Led s ynature: .•...4zww, w�r� . LNP,fBit',r_,��� ---, POSTRUCTION LENDING AGENCY: lE•�' ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then live hundred dollars($500).): ❑ I,as owner of the properly,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of properly who builds or Improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person Is required to descend,will be made In connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has e permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes ❑No (Section 25505 of the California Health and Safety Code requires,with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the Califomia Health and Safety Code been fully complied with? 0 Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apAermit for such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency? 0 Yes IJ No (Section 65850.2 of the Califomia Govemment Code requires that the requested Information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Duality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S. nature f Lege I Own (p s) Dgte / r /< .,�ndlO hdrizedApplicenntt :. a � D`ete Ff-�,b!/ aua .T..�vhc, ..�r$s. CODES INSPECTIONTYPE PATE INTmAs$ CODES INSPECTION TYPE PATE I1com9L6 1616 Fixed System Final Fire Prevention 206 Final Mechanical L� 1266 Pool Spa Final 208 Final Plumbing —Pi T -07 -13-17 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy