HomeMy WebLinkAbout1011 NANCY LN - Building PermitsCITY OF COSTA MESA
osTp„FS; BUILDING DIVISION
77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
F
� FOR INSPECTIONS CALL: (714) 754.5626
PERMIT NUMBER: BC09-00134
PERMIT TYPE: B_COMBO STATUS: ISSUED
Sub Type: RES -ALT DATE ISSUED: 04/24/2009
ISSUED BY: RMID
JOB ADDRESS: 1011 NANCY LN CM Suite/Unit:
APN: 93530018 Zoning: ,
Vicinity: SECOND FLOOR BATHROOM Primary Occ: R-3 CA(:
Const Type: V -B SO. FT: 0 Valuation: $4,900.00
SCOPE OF WORK: MINOR 2ND FLOOR BATHROOM REMODLE. REMOVE EXISTING BATHTUB AND REPLACE WITH SHOWER.
REVISED: 5/4/09- WINDOW REPLACEMENT. INSPECTION FOR ANY WINDOWS WHERE STUCCO IS BROKEN. NO
ENLARGEMENT OF WINDOWS EXCEPT MINOR AREA FOR FITTING OF NEW WINDOWS. NO NEW WINDOWS.
REMOVE EXISTING SIDING UNDERNEATH THE WINDOW AND INSTALL 7/8" STUCCO.
OWNER: GOMEZ, MICHAEL Address: 1011 NANCY LN Unit:.,,�Yr J1��
Phone: 949-722-8702 City/State/Zip: COSTA MESA, CA
APPLICANT: GOMEZ, MICHAEL A
Phone: 949-722.8702
CONTRACTOR: OWNER -BUILDER
Phone:
Cell:
ARCHITECT:
ENGINEER:
COMBINATION PERMIT FEE SUMMARY
Building Plan Check:
Building Fees:
Electrical Fees:
Mechanical Fees:
Plumbing Fees:
SMIP Residential:
SMIP Commercial:
Bldg Std Admin Fund
TOTAL FEES:
-'Refer to foo receipts for all fees paid for project
Address: 1011 NANCY LN
City/State/zZip: COSTA MESA, CA
Address: Unit:
City/State:
License No.
License No.
$0.00
$111.25
$0.00
$0.00
$33.30
$0.50
$0.00
$1.00
$146.05
License No. 000000
Unit:
ZipCode
PHONE:
PHONE:
I H JH OW Erl.
it:
r`r
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.
CODE t. INSPECTION TYPE DATE INTmAL CODE INSPECTION TYPE DATE IN AL
VC'
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing 1— Z —O
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
(�Le�
204
Final Demolition
250
Final Building/Occupancy
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:
(Alis section need rpt be completed Jdle pemIN S wah ed at me hun aired deBars (Slee) orlew )
Policy Number:
❑ 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 lam of California, and agree that if I should
become subject to the workers' compensation provisions of Section 3700 of
the Labor Code, I shall forthwith comply with these provisions.
Applicant's Signature
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm 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.
Lic. #
Contractor's Signature
Class #
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, Gvil Code).
Lender's Name:
Lender's Address:
Signature
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.).
k6
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.contmclor(s) license pursuant to the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
LS c� o s
rSignature Date
305746 110 7)
Owner ID verified by driver s'license. arYes ❑ No
Driver's License No. Expires:
-Verif— Ication� Ownership y,(type of document, i.e. - rope y 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, An 2, Sec, 341, Title 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 permit to do such work from the division.
Applicant's 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? ❑ Yes ❑ No
(Section 25505 of the Califomia 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 might 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? ❑ 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 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 a permit for such construction
or modification from the South Coast Air Quality 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 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 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? ❑ 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 stale 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 pur oses. I agree not to occupy or allow occupancy of any building
authorize y� is penmil u 'I fn inspection.
Sigpature of Legal Owmegs) Date
Andlor Authonzed Applicant Date
R CITY OF COSTA MESA
q'"p MFsq BUILDING DIVISION
F� 77 FAIR DRIVE, COSTA MESA. CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 1
FOR INSPECTIONS CALL: (714) 754.5626
PERMIT NUMBER: BC09-00134
PERMIT TYPE: B COMBO STATUS: ISSUED
Sub Type: RES—ALT DATE ISSUED: 0412412009
ISSUED BY: RMD
JOB ADDRESS: 1011 NANCY LN CM Suite/Unit:
APN: 93530018 Zoning: ,
Vicinity: SECOND FLOOR BATHROOM Primary Occ: R-3
Const Type: V -B SO. FT: 0 Valuation: $3,900.00
SCOPE OF WORK: MINOR 2ND FLOOR BATHROOM REMODLE. REMOVE EXISTING BATHTUB AND REPLACE WITH SHOWER.
OWNER: GOMEZ, MICHAEL
Phone: 949-722-8702
APPLICANT: GOMEZ, MICHAEL A
Phone: 949-722-8702
CONTRACTOR: OWNER -BUILDER
Phone:
Cell:
ARCHITECT:
ENGINEER:
COMBINATION PERMIT FEE SUMMARY
Building Plan Check:
Building Fees:
Electrical Fees:
Mechanical Fees:
Plumbing Fees:
SMIP Residential:
SMIP Commercial:
Bldg Std Admin Fund
TOTAL FEES:
"Rotor to fee receipts for all fees pale for project
Address: 1011 NANCY LN
City/State/Zip: COSTA MESA, CA
Address: 1011 NANCY LN
City/State/zZip: COSTA MESA, CA
Address: Unit:
City/State:
License No.
License No.
$0.00
$97.25
$0.00
$0.00
$33.30
$0.50
$0.00
$1.00
$132.05
License No. 000000
Unit:
Unit: .
ZlpCode
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.
CODE i. INSPECTION TYPE DATE INTMAL CODEt INSPECTION TYPE DATE INTITIALS
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 BlocIJRetaining 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 BuildinglOccupancy
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 carder and policy
number are:
Carrier:
(This sediln need not De completed Athe permit is mfived at prathundred dollars (5100) w fess )
Policy � Number:
Orcertify 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, and agree that if I should
become subject to the workers' compensation provisions of Section 3700 of
the Lab Code, I shall forthwith comply with these provisions.
Al' 3Signatdre' " 4..Da!e s
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm 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.
Lic. #
Class #
Contractor's Signature Date
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
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
f ovqhundred dollars ($500).):I,as owner of the property, or my employees with wages as their sole
ensation, WILL DO THE WORK, and the structure is not intended or
oered 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.).
leas 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:
6__ Y -may rJ s
[-Slinshini " Date
705]-461310]
Owner ID verified by drive, . license. es ❑ No
Drivers,License No.,
Expfres:_//-
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 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.
AOplieanl's Signature
Division of Industrial Safety Permit Number:
Date
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? ❑ 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? ❑ Yes ❑ 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 might of 500 pounds, or a
volume of 55 gallons, or 200 cubic feel 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 a permit for such construction
or modification from the South Coast Air Quality 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 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 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? ❑ 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.
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
authorizedby t permit until fina n. inspectio
�? sago f
SgnaMearLedal Oaner(s)_?-s�
Andlor Authorized Applicant
®Sta I�1�S�
C y of Costa Mesa Builu vng (Divisioll
77 Fair Drive, Costa Mesa, CA 92626
714-754-5273 / Fax 714-754-4856
OWNER BUILDER VERIFICATION
Permit # f�oq l 61 �
Disclosures & Forms for Owner- Builders Applying for Construction Permits
Dear Property Owner
An application for a building permit has been submitted�fyour listing yourself as the builder of the
property improvements specified at ill 11 N 4/%,1
Vve are providing you with an Owner -Builder Ac crow e�ent and Inf rmation Verification Form to make you
aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of
each provision, signed, and returned this form to us at our official address indicated. An agent of the
owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting
authority.
OWNER'S ACKNOWLEpGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each sta ement below to signify you understand or venIfyhis information.
M�'Z)Iunderstand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and
material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any
injuries sustained by an unlicensed person and his or her employees while working on my property. Aly
homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder
and am aware of the limits of my insurance coverage for injuries to workers on my property.
X21 understand building permits are not required to be signed by property owners unless they are
responsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
C0l?F I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that
I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his
or her name instead of my own.
$n�.Pr�4 I understand Contractors are required by law to be licensed and bonded in California and to list their
it cense numbers on permits and contracts.
W�5? I understand if I employ or otherwise engage any persons, other than California licensed Contractors,
and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may
be considered an "employer" under state and federal law.
�6. I understand if I am considered an "employer" under stale and federal law, I must register with the state
and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and
contribute to unemployment compensation for each "employee." I also understand my failure to abide by these
laws may subject me to serious financial risk.
At k-7 .6 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed
by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of
the work is performed under contract with a licensed general building Contractor.
168. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, 1 may be held liable
of r—any financial or personal injuries sustained by any subsequent owner(s) that result from any latent
construction defects in the workmanship or materials.
1 of 2
L(IS .-I understand I may obtain more information regarding my obligations as an "employer" from the Interna
Revenue Service, the United Stales Small Business Administration, the California Department of Benefit
Payments, and the California Division of Industrial Accidents. I also understand I may contact [lie California
Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information
about licensed contractors.
f- 1.0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand
t I am the party legally and financially responsible for proppsed construction activity at the following address:
v
1.1 I agree that, as the party legally and financially responsible for this proposed construction activity, 1 will
abid be y all applicable laws and requirements that govern Owner -Builders as well as employers.
M_ 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
in of rmalipn I have provided on this form. Licensed contractors are regulated by laws designed to protect the
public. If you contract with someone who does not have a license, the Contractors' Slate License Board may be
unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against
unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed
Contractor or employee of that individual or firm is injured while working on your property, you may be held
liable for damages. If you obtain a permit as O•,vner-Builder and vAsh to hire Contractors, you will be responsible
for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage. t'
Before a building permit can be issued, this form must be completed and signed by the property owner
and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's
driver's license, form notarization, or other verification acceptable to the agency is required to be
presented when the permit is issued to verify the property owner's signature.
Si
Note: The follo'rving Authorization Form is required fo be completed by the piopeny owner only when
designating an agent of the property owner to apply for a construction permit for the Owner -Builder.
MIZATION OF A(
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility
hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents
necessary to obtain an Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled
out the above informalion and certify its accuracy. Note: A copy of the owner's driver's license, form
notarization, or other verification acceptable to the agency is required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: Date:
2 of 2
Ai "•oE3ullmic:
1011
NANCY LN
UNIT:
CITY OF COSTA MESA — BUILDING PERMIT
vxNE�EIR IDfOWN:
MICHAEL
GOMEZ
AWREss:1011
NANCY LN
C.M.
CA 92626
PERMIT NO: B 087265 PLAN CHECK NO: N
APPL."LING ADDEM
CONSTRUCTION TYPE: V—N PERMIT TYPE: STR
ARClInCTORENINETN:
UC. NO.:
JOB DESCRIPTION 1 LAYER COMP. OVER EXIST. 1 LAYER COMP
WR. OR ENG.'S ADDRESS:
UNIT:
cgxrRACTaySNANE:ISLAND PACIFIC ROOFING (714)637-2493
CONTIACTORSMAILM 17762 CAMERON ST
ADDREss H. B. CA m No: 631472
92647 umT: 2
LICENSED CONTRACTORS OECLARATION: I Mreby aDkm under penalty of perjury tlM nder prwiwms d Chanter 9
(commenong with Section TOW) d Division 3 d the Sueinem and Prominence Code, end license Is r lull brte end "ed.
CIJLNO.:057P0/9 1LCcLAss:C 39 UkND°8314 2, .9Xp;, 09/9
a \Mywcn BUILDEff OECfARATION: 1 hereby affirm under peraly of b6rjury that I em exempt from the Contredwe License Law for ill
allowing lemon (Section 7031.5 Business and Professions Code: Any city or county which requires a Perms to construct, eller, improv,
bmoleh, or repel my structure, pity, to se asuence. also requiem the applicant for such perms to fib a signed statement that M writhe
is licensed un cost to the prweiwta of the Commence License Law lChepter 9 (ownmenong with Section ]0M) of Division 3 of the
Business and Prdmsicns Cade) or that M or she is mempt therehwn and the Were for the a sit exemption. My vMwion of Section
7W 1.5 by any applimnl for a Weis wbjeds the aPplicenl to a tang Penally Of eM mon than fns hundred ddlata (3500)).
❑ I, as owner of the popeny w my employees with wags a time sole comperammon, will w tM wodc, end IM structure is M intended
or Mend for ssb (Sectim lou, Bumnee end Pmfmsima Code: The Contractors License Law Eos net mdy tow ownerd property
who Mich or knpovm In.. and who data such work himself or Mreatl or through M or Mr own employees, pwidad that such
impo+emeds ala rM intended or Offered for sabs, howeme, tM Wilding or improvemed is am within one Year d mmpla on, the
owner builder will have the burden of proving M Or she did not Wil or impeow for the Wmme of sab).
I, m owner of IM property. mm exousMy comessing will Iicemsd contractors, to construct the project (Section ] . Business sad
Prosecutions Cob: The Contract. Lowest Law dorm not appy to an owner of Poll who Wilds or impwes thereon and who
contracts for such projects with a onlemon") licensed Pursuant to the Contractors License Law).
1 am exempt under Section: B. a P.C.. for this Beason:
Date: Owner.
I do haroby cMlfy, that I am aware of and understand the raqu erembal d Cdsomb Neellh and Safety Cade Sections 25505. 25533, and
25534, and that I or my Mum building mapenl will / will net Ionia one) need to campy with said oda cods and the roqu nernw a for
a WmdlwmtatrodionwmndiScaMnhwnlM Army anegemed Distinct. ReodunW mnmmdion Mlet iwuan exempt horn throe
prwlsiora.
Dale: Applicant:
WORKER'S COMPENSATION DECLARATION: I Mreby affirm under "natty of perjury ora of the following declarations:
1 Mve and ail mermen a certificate d wtrunt to seR4nwm fix waken' camp ion, m porvNed fw by Section 37W d the laser
Cods, for IM pMananpe of the wak for which this perms is valued.
0 I have and vis maintan w m' corm Wnsatnn inwrmw, m squired by Sersim 37M d the M Cnde, lore tM Wdormwca d tM
,work for which Mia Wets a aaued. MY waken' comWneation in.. center east policy number ora:
Canner:
Policy Number:
9 eedem need n«W cwnpbfad y Me Pew's for aro hmdred ddbes /31 MJ w
• tansy that iyy rhe Wdormema d tM work for which Ih13 Wets 1 shell nd employ pes,on in my mmrM co e to
become sub
to ha workers' comm __ lows of CalilOrnie, agrpe UW A daunt become
wbpd to ill worlan'
omp w 1 rl r io 1 S ion 3700 of the labor Cob. l pry wird IhWa pvmiwu
or
� Apd�rmb
Wam/ng: Ilan to smuro wpl3en' comparu.tlon cowreps /s unle , and alWl auW/ecf m employs for MMn.I pmaltlm and
e/M fres. , to ons hundbad om and ddbn ffiggGM), M abftlon b Ma cost o/ eampsne.florn, bmNps a provldsd 'Is
SecdW 3706 of fM Labor Cob, InMm4 and effomery's feu.
CONSTRUCTION LENDING AGENCY: I hereby affirm under Penalty d perjury that there Is a conmmmdion lending agency, for the
mme d the
padwework for which the Wms b Issued (Section 3097. Cil C).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that I have reed this a,,lcwion and mate fuel the above iedmnatim Is noted. I ague to campy with all city and county oldi.
and state was mating to Wilding construction sed Mreby authorize reprauniwivae of w
this city lo enter upon the shwa -mentioned pmpedy
for inspectlo^ Wrooms,
MIR/A/NDA( D��
X15151 -ere WPI Whsa-Buibig S Selli Green-RN-9diiery-AppYmnl: Pink -Revenue: GoManmd-Msemw
PERM NO: B 087265
GOVT: N SUPP: N
PURPOSE: OTH
SQ FT: 1,366
CLAIM VALUE: 1,366,00 CALC—VALUE: 1,366.00 GROUP OCC: R-3 /U-1
COMMENTS: X
RP dt RE dt iE 9E*9E dEMit*df ilk dE dE Rt iE dE dF*dE dE iE RE it*RE RE RE RE*******dE RE dFrtiE**kdE db*iE dE iE iE*RE RF 9t RE*RE*RE RE dE RE iE dt*REiE*iF RP Rf*#RE RE*
Z 0 N I N G R E Q U I R E M E N T S
S E T B A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------
-9RNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
PARKING REQ: PROV: PARCEL: 93530018 ZNE: REF NO:
PLANNING NOTES>.
1E Rf 1E 9t iE kRE it 9E 9E iE dE 1E iE'iE iEriF,9E*RE iE iE 9E RE RE RE iE ib SF 009E RE iE RE iF iE RE iE*******4iE 7E 1f iE iE******iF*9E ilk iF****ii*it lE dF iE**iE*M*dF
D E V E L,O P M E N T S E R V I C E S R E Q U I R E M E N 3'! S
ZONING APPROVED'BY DATE:
BUILDING APPROVED BY DATE:
APPLICATION ISSUED BY: DATE:
iEiE**iE****4dE dE*iFRE**RlkiF it it3F3FifiF3FiF7i�FiF�7F3fif3E3Fifif'�i(�iF3f3fiEiF�3FiFiF lE if iE iF lE lfiE lk lE it 3E iE
LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGM T:Y
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT 45.75 50
SMIP/NON—RES
PLAN
ISSUE FEE
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS ---- > 46.25 0.00 0,00 46.25 46.25 ,00
REVENUE DIVISION TOTALS--> COLLECTED: 46,25 OVER/SHORT: .00
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
45.75 ,50
RF RE iE 9E iE*iF dE RE iE*RE df *Rf Mot Rb**ilk*9E Rb dE******dE dt dF*RE iE***RE****iE dE if*iE**9E**1k kRE iE Rb**dE dE dE dE RE iE dE 9E**dE lE RE iE*iEk
I N D I V I D U A L F E E B R E A K D O W N
TY E (TY D E S C R I P T I O N UNIT COST TOTAL COST
SFR 1366 REROOF BY VALUE RESIDENTIAL NOZONE 1,00 I366.00
END OF FEES T t
�pR 111998
CONSTRUCTION AND PLANNING
POUL & SPA
,
APPROVALS Permit #
Date
Inspector
APPROVALS r Permit #
Date
Inspector
1. Temporary Electrical Service.ortPole
52. Pool & Equipment Location
'
2. Soil Pipe-Undrgrnd.. _'
53. Steel Reinforcement
,I-'.3. Electrical Conduit Utility-Undrg�jnd.
54. Forms
4: Electrical Conduit-Undrgrnd. "
55. Electrical Bonding
5. Steel ReinforcemAnt
56. Rough Plumbing & Pressure Test
�'6"_Electrical UFER Grnd.
57, APPROVAL TO COVER-GUNITE
`
7t Footings •r :-
58. Electrical Conduit-Undrgrnd.
8. Foundation
59. Gas Pipe, ❑ Undrgrnd., Test
9. Water Pipe-Undrgrnd.
60. Backwash Lines, P -Trap, 0 Undrgrnd.
10. Structural Floor -System .. �'
61. APPROVAL TO DECK
11. Property Sewer -Line& House Connection
62. Backwash &Rtceptor-Final
12. Sewer Cap
63. Heater & Vent -Final
13, Roof Drains -
64. Plumbing System - Final '°
14. Rough Plumbing -;�_
65. Electrical -Final
15. Rough Electricat-Conduit •••-,fr
66. Solar System -Final
"
16. Rough Electric -Wiring'
67. Fencing & Access Approval
17. Rough Wiring Sign -.. e'�
68. APPROVED FOR PLASTERING
18. Rough Electrical -T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. -_ Rough Huting&Air Conditioning ���
L
_' FIRETDEPT:REQUIREMENT :t
APPROVALS -'t"' Peimit # '. F ---
eq
20. Rough Factory Fi�e�lace
��{
_'•
1.� 7 Q
21. Ducts,in`Structure +
_ -
. �:-
-
70.°Underground 18gdro
22. Ducts, Ventilating-? .fi•-
'-'
-,i
71. ProcWctTioing-OGas 0 Oil
23. Gas.Pipe-Rough &Test
72. Underground Flush� t ,
24. Roof Framing >; ti .y T,.,
25. Roof -.Sheathing* :; %.�'J3'y'
`�H�'
N/Y,.'
73; Undergrnd.Storage=T_,anl�`,0Gas -E3 Oil
7,,Dverhead Hydri7
26. T -Bar Ceiling (Structural) & ModocoatVim'_
i al .-
75: -Ory Chemy
r
-1
,r
-, 27. ,.Frame and Flashing __
,
-
76. Dry Staodpipe.<-1
. 28. Lathing & Siding ''r''- _
I'
77_ FIXED SYSTEM FINAL
• 29. Insulation 'S
# •:,
I
78!: FIRE PREV. F11`If1L -
1
30. Drywall Nailing
HEALTH DEPT,REQUIREMENT
31. Plaster Brown,Coat `.
-
79. FINAL INSPECTION .=
,t
-
' 32. Electrical Power Meter-pinal•,
80, FOOD CE RTIRIC ATE 1S30ED'
n'
33. Tinat!Electric. �
�
Notes:
. _ _
....
t 34. -Fin4Heating-& Air Conditioning
35. 'F.inal Gas Pips=Test r
36. Hood.orCanopy
ICS
x n
'1 �i
37. Final'Factory Fireplace.
n,
_p
: 38. Final.Plumbing
39. Water Seivice_Final
v "'
r,.1 x r.
•_t
7 40. Gas Servlce•Final ~ " "- -
,n
'^ ",
_
,. - •..
41. Solar Domestic -Final
r
-• lk
m
42. Back flowPreventer-., t' _
rr
n ;n^"u
43. Backflow Irrigation
Y 3' -
44.'Landscape, Irrigation System s
". rt*
w
45. 'Sound Attenuation' =
-`
`t .-._ '
46. Handicap Regulations _ ..
� S �
I
p
--jru_ .-
47. FINAL STRUCTURE & BUILDING
48. RINA'L PLANNING;`
49. Electric Release to Edison
'
! - ��•��
�: _
u
_ •1z
_':�
J '- r.
50. Gas Release to'SoutAern California -Gas Co
51, CERTIFICATE OF OCCUPANCY
No. Date
Memorandum
To: Development Services
From: Dusty Bent, Treasury Management
Date: March 23, 1998
Re: RETURNED CHECK
The following check did not clear the bank:
Island Pacific Roofing - $138.75 - Amount now due $158.75
Please do uorgive any further inspections for Permit #B087263, B087264 and B087265 until
payment has been received by this office.
t Should you_have_any questions, please contact me at X5072.
t .-
�NI IA. I
Ibm oa/ol(
City of Costa Mesa Plan Department
Post Office Box 1200
77 Fair Drive
Costa Mesa, California 92626
U 19�U (714) 556-5245
REQUEST FOR OCCUPANCY
(Single Family Residential or
Condominium Units)
Tract No. ! 6/ l
Lot No.
Address /4// ZAJ.
Date /a d
11 11
The developer of the above entitled tract desires to sell the above
set forth lot prior to the time that the tract has been completed and its streets
accepted by the City of Costa Mesa.
The undersigned, by executing this agreement, acknowledges that
(hey-sh* they) (was or were) rv6 advised that this tract has
not been given final inspection nor has it been accepted by the City of Costa Mesa
as having complied with the conditions of approval which were imposed by the
City at the time the final tract map was approved.
The City assumes no liability for the enforcement of the conditions
necessary for approval other than those conditions protected by surety bond.
The undersigned agrees to indemnify and hold the City harmless
from any claim resulting in damage or personal injury to the undersigned by
reason of the aforementioned uncompleted condition.
By
Purchaser
By
De eloper and or Authorized
Representative
By Lende_
CMF 0569-26
Ai
OWNER BALALIS & PIGNMI DATE 4-26-77
JOB ADDRESS lopC Olog 101-1 Nancy T�ane BUILDING PERMIT N0. 4
GENERAL CONTRAR Ovner-Bldr. DESCRIPTION of WORK Triplex w garages
AP N01T5-02R-11 LOT TRACT 4641 FIRE ZONE VALUE ST2n_ann_nn
INSPECTIONS pt Al
Si noture
Date
TYPE v GROUP
g L T ZONE _
SOIL
z.
SUBCONTRACTOR
GAS
Date Number
Signature
WATER 1-11,r1, .77
Plumbin
ROUGH PLUMBING
PROP. SWR. LINE ❑ HOUSE CON.
.20.7
i 0
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUND ❑ POWER E)
ROUGH WIRING
03L'
%
Ne tin d Y nf,
TRENCHES W FORMS IN STEEL REINF.
14v yfj
FLOOR SYSTEM
BOND BEAM "STEEL REINFORCE
SHEATHING
7
FRAME AND FLASHING
if
•i
LATHING — IN OUT
PLASTER, BROWN COAT
STRUCTURAL, FINAL
HEATING, VENT., REFRIG. AND A.C., FINAL
-I 14A.10
PLUMBING. FINAL AND GAS TEST
ELECTRIC, FINAL
G
BUILDING. FINAL
SPECIAL REQUIREMENTS
17-
"35
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to FID in Completely — Use Ink Only
BUILDING
ADDRESS /007-/009/ 10/1 11ANCY
OWNER f3gi t/d T n4wjw i
MAIL
ADDRESS 20/S UA /519141011 /Sc.✓
TEL.
CITY /i/C.u,'fJrKT /?F71G FI NO.,
BRANCH
ARCHITECT ,
OR ENGINEER /y;//&1 C- I N /
ADDRESS
APPJATION FOR STRUCTURAL PERMIT
FIRE
ZONE
APPROVED
DATE 't- -,4(,
ADDRESS
TE RECEIVED D TE ISSUEPER
NO.OF USE OF N
PLA BUILDING
TEL.
-3
CITY NO.
"No
JA)
YARDS APPROVED YARDS APPROVED
�Q�I Ajkmla
UAN
LOT BLOCK
(FROM C/L S EET)
W
PLU
NO. OF BLDGS.
d
OF LOT
NOW ON LOT
ROM FT. FT.
ierAlEX1VALUE
USE OF
EXISTING BLDG.
R.SIDE 3SFT.1_FT
y
FIRE
ZONE
APPROVED
DATE 't- -,4(,
0
ADDRESS
NO.OF USE OF N
PLA BUILDING
TEL.
F
CITY NO.
STATE CITY
YARDS APPROVED YARDS APPROVED
LIC. NO. LIC. NO.
MAIN BUILDING ACCESSORY BUILDING
(FROM C/L S EET)
W
SIZE
NO. OF BLDGS.
d
OF LOT
NOW ON LOT
ROM FT. FT.
Q
USE OF
EXISTING BLDG.
R.SIDE 3SFT.1_FT
y
Separate permits are required for
L SIDE FT. FT.
electric, plumbing and heating work.
G1
REAR FT.Z267 FT.
BUILDING AND W BE OR ED
TO
DISTANCE BET. BET. MAIN &
Q�
1 -i' G G N�RK
a
MAIN BLDGS. ACCESS BLDGS.
VAR sF) DATE
Q
C.U.P. - —.2)4 L-117- �
7
APPRO
JRY
-DATE
a
w
0
I hereby acknowledge that 1 have read this application and state
19
that the above Information Is correct and agree to comply with
"• m
p+
all laws regulating building construction, and lahnll not employ
i
Z
any person in violation of the workman's compensation laws of
-- - '—
the State of California.
-
I hereby certify that I em properly licensed as a contractor under
SO. FT. SIJ UI
THE AMOUNT SHOWN UNDER VALUATION IS FOR D
the State of California Business and Professions Code. Division 3,
Chapter 9, and that such licenses are in full force and effect, or I
THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY;
em exempt from th rovislons Of the State of Calitornle Business
a
antl Professions Co , Dbis on 3, C aPter
VALUATION
PERMIT FEE S
PLAN CHECK $047 G
Signature of
Permittee
a� /1
$�_///led
TAX S j
u
-LITE/C
TOTAL PAID i!il.:^_ I
Author zad Agent
0