HomeMy WebLinkAbout3252 NEBRASKA LN - Building PermitsCITY OF COSTA MESA
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> � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
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�.���� FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER: E10-00209
PERMIT TYPE ELEC
APN: 13906505
JOB ADDRESS: 3252 NEBRASKA LN CM
Vicinity:
STATUS:
DATE ISSUED:
ISSUED BY:
Suite/Unit:
ISSUED
09/07/2010
RMD
SCOPE OF WORK: ELECTRICAL PERMIT FOR i OUTLET AND 1 SWITCH TO INSTALL A NEW TANKLESS WATER HEATER. REF#:
P10-00124 �
OWNER: SMITH PERRY G AND ELIZABETH A Address: 3252 NEBRASKA Unit:
PHONE: 714-979-6559 City/State2ip: COSTA MESA, CA
APALICANT: PIOTROWSKI, PHILIP Add25s: Unit:
PHONE: 800-655-7798 City/Siate/zZip:
CONTRACTOR: PHILS PLUMBING ADVANCED MOBILE SHOPS License No. 506677
Address: 19140 DEMETER AVEUnit: . PHONE: 800-655-7798
City/State: CERRITOS, CA ZipCode: 90703 CELL:
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $25.70
Reinspection F�e $0.00
TOTAL FEES $25.70
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, i2-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authonzetl under this pertnit lo be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obiained. FaiWre to obtain inspections and final approval vnll result in the expiretion of this permit.
CODEt. INSPECPONTYPE DRTE INTITIRL COOEi INSPEC110NTYPE OAiE INnnnis
1618 Fixed System pinal Fire Prevention 206 Final Mechanical
1288 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical �C 9-� 3-ro N-�n�
ZOt finaBfocWRe�y(ning Wall 2i2 final fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 final Demolitipn 250 Final Building/OccuOancy
WORKERS' COMPENSATION DECLARATION:
I hereby affrm under penalty of perjury one of the following tleclarations:
❑ I have and will maintain a certificate of consent lo sel!-Insure for workers'
compensation, as provided for by sec�ion 3700 of Ihe Labor Code, for the
peAormance of the work for which this permit is issued.
❑ I have antl will maintain wnrkers' compensation insurance, as required by
section 3700 0( the Labor Code, for Ihe per(wmance ot the �+ork fw wfiich this
pertnit is issuetl. My vrorkers' compensation Insurance carrier and policy
number are:
ca`� �icL/�S //V� !'AMP
(Tn¢ secfion nee0 nd D,eIcwnp/e1fe0/ �dthe pe,rt1n�rt k valuetl al me hunOrM do/llIars (/St00/J a� less.)
�Po�lic~y Number. �L .//( /�/ i Z'L O ���y !O p,6
❑ I certify Ihat in the per(ormance of Ihe work for which Ihis permit is
issued, I shall not employ an person in any manner so as to become subject
to the vuorkers' compensa' n laws of alifomia, and agree that if I should
become subject lo the kers' com nsa[ion provisions o( Section 3700 of
the Labor Code, I sh rthwith co y with these provQisions.
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WARNING: F URE TO SEC E WORKERS' COMPENSATION COVERP,GE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
(5700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE IABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrtn that I am licensed under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of the Business and Professions Cotle, and
my license is in full forc nd e8ect. C_� �
Li� e�'.,#,` � O CCIassR#
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✓- on c x's Sign reh � �De�Ye�
CONSTR TION LENDI�G AGENCV:
❑ I reby aPorm ihat there is a constmctbn lending agency for the
per(ormance of the v.ork for wfiich this permit is issued. (Sec. 3097. Civil Code).
Lender's Name:
Lenders Address:
Signatore
Oale
OWNER-BUILDER DECLARATIONS:
I hereby aKrm that under penalry of perjury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW (or the following reason (Sec. 7031.5,
Business and Professions Code: Any ciry or counry which requires a permit to
constmct, alter, improve, demolish, or repair any slrucNre, prior to i[s
issuance, also requires the applicant for such permit to file a signetl statement
that he or she is licensed pursuaN to the provisions of the Contrac[ors
License Law (Chapter 9(commencing with Section 7000) of Division 3 of the
Business antl Professions Code) or that he or she is exempl therefrom antl
the basis for the alleged enemption. Any violation of Seclion 7031.5 by any
applicant for a permi� subjects the applicant to a civil penalty of not more Ihan
five hundred dollars ($500).):
❑ I, as owner of the property, or my employees vrith vrages as Iheir sole
compensation, WILL DO THE WORK, and the structure is not intended or
offered for sale (Sec. 7044, Business and Professions Cotle: The Contractors
License Law does not apply to an ovmer of properly who Duiltls or improves
thereon, and who does such vrork himselt or herself or through his or her ovm
employees, provided that such improvements are not intended or oRered tor
sale. If, however, Ihe huilding or improvement is sold within one year of
completion, the owner-builder will have the burden of proving that he or she
did not builtl or improve for purpose oi sale.).
❑ I, as owner of the property, am EXCLUSIVELY CON7RACTING WITH
LICENSED CONTRACTORS to consWct the project (Sec. 7044, Business and
Pmfessbns Code: The contractors License Law dces not appty to an owner of
property who builtls or improves thereon, and who contracts for such project with
a contracta(s) license pursuam to [he Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
JOS]-46 (9I01)
Owner ID verified by driver's license. ❑ Yes ❑ No
Driver's License No. Expires:
Venfcation of Ovmership by (type of document, i.e. - propeAy ta: bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby cendy that no excavation frve (5) or more teel in tlepth into which a
person is required to descend, vnll be matle in connectbn with wnrk authodzed
by this permit, and thal no building sWcture. scaf(dding, falsewark, a demolition
or dismantling thereof, will be more lhan thirty-six (36) feet high. (Chap. 3.2, Grp
2, Art 2, SeG. 341, Tlle 8, CalifOmia Atlmini5l2We Code).
❑ As owner-builder, I will not employ anyone ro do work which would
require a permit from Ihe Division of Industrial Sa(ety, a5 notetl above, unless
such person has a permit ro do such work from the division.
Applicam's SiBnaWre Da1e
Division of Industrial Safety Permit Num6er.
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or (uture Duilding occupant neetl lo fle and
certi(y a Business Plan for emergency response lo release or threatened
release of a hazartlous matenal? ❑ Yes ❑ No
(Section 25505 of the Califomia Health and Sa(ety Cotle requires, wilh some
exceptions, Ihat a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one lime tlunng a reportetl
year a quantity of hazardous matedals equal to or greater lhan a weighl of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressetl gas
at stantlartl temperature and pressure).
2. Does or will the applicant or present or tuture building occupant need ro file
a registration form for acutely hazartlous materials? ❑ Ves ❑ No
(Seclion 25533 of the California Heallh antl 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 [o or grea[er Ihan a weight o/ 500 pounds, or a
volume \o( 55 gallons, or 200 cubic feet of compresse0 gas at stantlartl
temperature an0 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�7 ❑ Yes ❑ No
(Section 25534 of the Califomia Heal[h and Safery Cotle 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
lo register acutely hazardous materials vnth the Fire Department.
4. I/ an RMPP is presently required, has Section 25534 of the Califomia
Health and Safety Code been fully complietl with? ❑ Yes ❑ No
5. Does or will the applicant or present or (uture builtling occupant require for
the vrork which is ihe subject of Ihis applica[ion a permil for such consVuction
or modi(cation from the South Coasl Air �ualiry Management District or trom
any other air polWtion control dislnct or agency? ❑ Yes ❑ No
(Sectbn 65850.2 of �he Califomia Govemment Code requires that Ihe requested
information be fumishetl on applications f« non-resitlential building pertnits�.
6. Will any part o/ the facility to be construc[ed under Ihis permit be within
1000 feet from Ihe outer boundaries of a school? ❑ Yes ❑ No
Qf'yes", the facility must meet the requirement of Sections 25534 and 42303
o( lhe Califomia Heali� and Sa(ety Code).
7. If a permit from Ihe South Coast Air Quality Management Districl or other
air pollution control district or agency is required for the work which is the
subjec� of Ihis applicalion, have all of Ihe disclosures prescribed by California
Health and Safety Code Section 42303 been made? ❑ Yes � No
8. (If yes", attach certificate of compliance trom the appropnate air pollution
control oKcer�.
CERTIFICATE OF COMPLIANCE: I certify tha[ under penalty of perjury the
information given above is correcL I agree to comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
Signalure Oale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify untler 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 antl city
ordinances relating to builtling construction, and authonze representatives of
the City of Costa Mesa to enter upon t e above-described property for
inspection purposes. I agree not to occup r allow occupancy of any builtling
aulhorized by Ihis permi� unjil• ir I inspe on.
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CITY OF COSTA MESA
a �yjpMFsq B!/ILDING DIVIS/ON � � �
>�� 77 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Faz (714) 754-4856 • www.ci.wsta-mesa.ra.us
:
° � FOR INSPECTIONS CALL: (714) 754-5626
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PERMIT NUMBER: E10-00203
PERMIT TYPE ELEC STATUS: ' ISSUED
APN: 13906505 DATE ISSUED: 08/2512010
ISSUED BY: KJB
JOB ADDRESS�34�52-„N. EBRASFVW''L'N`. CM'�"`?+� Suite/Unit: � �
Vicinity: . � . n : '! � y.
.. ' '-- , '. _ ' _F .� ' �.j . : .
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SCOPE OF WORK: SERVICE UPGRADE FROM 100 AMP TO 200 AMP. SERVICE TO REMAIN IN THE SAME LOCATION. �
OWNER: SMITH PERRY G AND ELIZABETH A
PHONE:
APPLICANT: SMITH, ELIZABETH A
PHONE: 714•979-6559 �
Address: Unit:
City/State:
PHONE:
ZipCode:
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $54.00
Reinspection Fee $0.00
TOTAL FEES $54.00
Address: 3252 NEBRASKA Unit:
City/State/Zip: COSTA MESA, CA
Address: 3252 NEBRASKA Unit:
City/State/zZip: COSTA MESA, CA
License No.
CELL:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Cali(ornia statutes and related
regulations. (Ord. N4. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT El(PIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit lo be considered legal, such work must comply with all applicable wdes, 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.
COOEi. INSPEC110NTYPE ORTE INTITIRLS CODEO INSPECTIONTYPE DRTE INTITIpLS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 270 Final Electncal % 0 4�
201 Final Block/Retaining Wall 272 Final Fire Prevention J
202 •Final Factory Fire Place �'• � (� •� 220 Final Planning Approval � �
203 �' FinafSign ' �' �� J �• ( ; • � \ 222 Final Site �' 1 � � � .
\ � 1�—
204 Final Demolition � 250 Final Building/Occupancy � ' �`\
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WORKERS' COMPENSATION DECLARATION:
I hereby aKrm under p�nalty of perjury one of the following declarations:
t
❑ I have antl will maintain a certificate of consent �o self-Insure for workers'
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which Ihis permit is issued.
❑ I have antl will maintain workers' compensation insurance, as required by
sectbn 3700 of the Labor Cotle, for the pedortnance of the wurk (or which ihis
pertni[ is issuetl. My workers' compensation Insurance carrier and policy
number are:
Carrier
(This sedion nretl iro! be m le(etl d �e peimR is valuetl af e �undmd dollars (5100) orlessJ
Policy Number: �
i
ertify Ihat in the performance of th ork for which ihis permit is
' e I shall not employ any person in any manner so as to become subject
lo the vrorkefs' Compensation laws o( California, and agree tha[ i! I 5hould
become subject to the vrorkers' compensation provisions of Section 3700 of
the Lab /�o I shall fort with comply with these provisio . �
� i o s. ig aWre . ���ate'— %
WA NING: 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 affrm thal 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 ef(ect.
Lic. #
Class #
Conuactor's Signamre oa�e
CONSTRUCTION LENDING AGENCY:
❑ I hereby aKrm that ihere is a consWctbn lentlinq agency for the
pertormance of the vqrk for which this pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Address:
SgnaWre
Date
OWNER-BUILDER DECLARATIONS:
1 hereby affrm lhal under penalty of perjury ihat I am EXEMPT FROM THE
CON7RACTORS LICENSE LAW for the following reason (Sec. 7031.5,
Business and Pmfessions Code: Any ciry or counTy which requires a permit to
construct, alter, improve, demolish, or repair any stmcture, prior to its
issuance, also requires the applicant for such permit to fle a signed statement
[hat he or she is licensed pursuant to Ihe provisions of the Contractors
License law (Chapter 9(commencing with Section 7000) of Division 3 of the
8usiness and Protessions Code) or that he or she is exempt theretrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects lhe applicant to a civil penalry of not more �han
five hundred dollare ($500).):
❑ I, as ovmer of the property, or my employees vnth wages as their sole
compensation, WILL DO THE WORK, and the structure is not intended or
oRered for sale (Sec. 7044, Business and Professions Code: The Contrectors
License Law does not apply to an ovmer of property who builds or improves
thereon, and who does such work himself or herself or through his or her own
employees, provided ihat such improvements are not intended or offeretl for
sale. If, however, the building or improvement is sold within one year of
completioq the owner-builtler vdll have ihe burden of pmving ihat he or she
did no ild or improve for purpose of sale.).
I, as ovmer of the property, am EXCLUSIVELY CONTRACTING WITH
LI NSED CONTRACTORS to construct the project (Sec. 7044, Business and
Professbns Code: The contractors License Law dces not appty to an owner of
property who builds or improves thereon, antl who contracts for such pmject vrith
a contract«(s) license pursuant to the Conlractors License Lavrs.).
❑ I am exempt under Sec.
Business and Professions Code for �his reason:
C�
aW �F3ate=
34 -48(3/W)
.� �
Owner ID verifed by drrver's license. ❑ Yes ❑ No
Driver's License No. Expires:
Veri(cation of Ownership by (type of document, i.e. - property taa bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby cert'rfy �hat no excavation frve (5) or more (eel in tlepth into which a
person is required to descend, will be made in conneclqn with wnrk authorized
by this permil, and that no building structure, scaHdding, false�wrk, a tlemolition
or dismantling thereof, will be more than lhirty-six (36) fee[ high. (Chap. 32, Grp
2, Art 2, Sec. 341, Title 8, Califomia Administrative Code).
❑ As owner-builtler, I will not employ anyone to do vrork which would
require a permit from Ihe Division of Indusirial Safely, as noted above, unless
such person has a permit to do such work from the division.
Applicanfs Signalure
Division of Industrial Safety Permit Numbec _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to (le and
certify a Business Plan for emergency response to release or threa[enetl
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some
exceptions, thal a Business Plan be filed wi�h Ihe Costa Mesa Fire
Department by every business which has a[ any one time during a reported
year a quantiry of hazardous materials equal to or greater [han a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic leet of compressed gas
at standard temperaWre and pressure).
2. Does or will the applicant or present or Nture builtling occupant need to fle
a regishation form for acu[ely hazartlous materials? ❑ Yes ❑ No
(Section 25533 of [he Calilornia Health an0 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 awtely
hazartlous materials equal to or greater than a weigh[ of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at stantlard
IemperaWre and pressure).
3. Does or will the applicant or present or fulure building occupant need to
prepare an RMPP (Risk Management and Prevention Program tor awtely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of Ihe California Health and Sa(ety Cotle provides Ihat ihe
Costa Mesa Fire Department may require the preparatioq certification antl
filing with the Fire Department of an RMPP by businesses which are required
lo regisler acutely hazardous materials with the Fire Departmenl.
4. If an RMPP is presently required, has Section 25534 of ihe California
Health and Safely Code been lully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future builtling occupant require for
the work which is the subject of this application a permit for such construction
or motlificalion (mm Ihe South Coast Air Quality Management District or (rom
any other air pollution con[ml disUict or agency? ❑ Yes ❑ No
(Section 65850.2 of the Califomia Govemment Code requires that the requested
infortnation be fumished on applications fa non-residential building permits).
6. Will any part of the (acility to be consiructetl under this permit be within
1000 (ee[ from the outer bountlaries of a school? ❑ Yes ❑ No
Q('yes", Ihe facility must meet the requirement of Sections 25534 and 42303
of Ihe California Health and Safety Code).
7. If a permit from the South Coast Air Quality Management District or o[her
air pollution control distric[ or agency is required for the work which is lhe
subject of this appliwtion, have all of the disclosures prescribed by Califomia
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
8. Qf'yes", attach ceAificate ot compliance from the appropriate air pollution
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify ihat untler 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.
Signalure Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRV: I
certify under penalty of perjury Ihat I have read �his application and sta[e that
the information given is correct. I agree to comply vnth all state laws and city
ortlinances relaling to building constmction, antl authonze representatives of
the City of Cosla Mesa to enler upon ihe above-described property for
inspec[, >u�p ses. I agree not to occupy or allow occupan y of any building
authoytil�bj t 1� 1 i,Epermit unti �qal inspection. O
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ti6ioriebrt,of,le�oal_.Own_erf`_`i Uate
An410r AutbOnxetl Appl¢ant
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Costa Mesa
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City of Costa �Vlesa �uiCding �ivision �
77 Fair Drive, Costa Mesa, CA 92626 .
714-754-5273 / Fax 714-754-4856 � � .
OWNER BUILDER VERIFICATION
Permit# ��v' �d�v3
Disclosures 8� Forms for Owner- Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner: '
An application for a building permit has be i in your na e If ting yourseI( the builder of the
property improvements specified at ���� �,�� l�a-S `�
We are providing you with an Owner-Builder Acknowledgment and Information 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 ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
�'�1. I understand 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 py an unlicensed person and his or her .employees ;while working on my property. My
,,' �• Fiomsawne'r's i��urance may not provide coverage for those';injuries..l am willfully�acting as an Owner-Builder
� � and�am �aware of the limits of my insurance coverage for injuries 1'o'workers on rtvy property.
�� `..
I 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.
ea/`�.
� 3. 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.
�4. I understand Contractors are required by law to be licensed and bonded in Califomia and to list their
license numbers on permits and contracts.
�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 state 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.
�7� I 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.
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3148-30 CALBO Jan 1, 2009 OB Packet template T Of 2 ��
�''—� & Pund"erstand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable
for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent
construction defects in the workmanship or materials.
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9•1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit
Payments, and the California Division of Industrial Accidents. I also understand I may contact the California
Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information
ab ut licensed contractors.
�� 0
-+l:i�=- 0 I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand
that I am the party legally and financially responsible for proposed construction activity at the following address:
�//,a' ��`7�11?I agree that, as the party legally and financially responsible for this proposed construction activity, I will
�abide by all applicable laws and requirements that govern Owner-Builders as well as employers.
.... , y .
���12, I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information 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' State 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 Owner-Builder and wish 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.
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 u to verify 3h,e, property owner's signature.
_SiqnaEure�of•property-own r, � �A/i"l V 1 CDate��j�j�� �� ,��'�
Note: The following Authorization Form is required to be completed by the property owner only when "
designating an agent of the property owner to apply for a construction permit for the Owner-Builder. '�,'
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I.�
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 information and certify its accuracy. Note: A copy o( 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:
��3148-30 CALBO Jan 1, 2009 OB Packet template 2 Of 2
ADGIICant to /ill in all space! except tho5e within heavY Oortler Iines antl sign all appr00��ate Eaeldralions.
` PER�p T NO. TRACT NO. LOT NO. UNIT N0.
I:YbFCOSTAMESA CONSTRUCTIONPERMIT (( A.P•# za�a
Project Address -� �'1'�S�Z N�r: (gjZIQSI�lb L�IJ � � S Main Building: Accessory Building:
Applicant'S Mailing�jAddre55 ��1 �� E TVPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR E Z
'=JIZ.LAT) GfiLLltG.I.CBrQ. p .SSYe�'fV3�/ � CONVERSION ❑ DEMOLISH ❑ OTHER ' 7 Front p
Owner's Name hone DESCRI�PI ION OF WORK�USE OF BLDG.'�� �"'''�'"~ A Rear N
Address 3a-'sy�/N/3i2vKKK Lq+liE. �-Wc�/ - I�-(A��/'
Arch/Eng. License No. TVPE OF PERMI AOING FOUNDATION STRVCTV RAL � K Aight N
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL i$' �ef� � G
Address p
Contractor's Nam Phone ❑�OTHER ping. Ref. # Parking Req./Provided E
� PROJECT DESCRIPTION . FT Z �' oCCUPANCV Planning Notes: M
Addresslmailingl— � - '/�
CONSTRUCTIONTYPE VALUATIOi�q/�r%d �
Ciry License No. T
ZONE GRA�INGCU.YDS. ACRES $,
LICENSEp CONTRALTOR OECLARqTION
I tlereby attirm lhat I am licensetl unqer provislons of Charter 9(commencing Remarks:
with section 7000� of Division 3 of the Business antl Professions Cotle, antl ELECTRICAL FEES
my license is in /ull tOrce antl eftect.
License Class License No.
Daie Siynature — PLUMBING FEES Automatic Washer Transformer ❑ 15-50 KW
WORKERS' COMPENSATION DECLqRATION ConstructiOn PoleSub. � 50+ KW
I ItereDy aifirm that I have a certificate ot consent to self-Insure or a certifiGate Bar Sink ShOw2f5
of Work¢rs' Compensation InSurdnce� O� a certlfletl copy ther¢Of ($ectlon COOking Unit Meter ❑up [O 1003rt1p5
3800, �ab. C.) Backflow Preventer Service Sink
Policy rvo. Company Backflow Irrigation Sewer Cap Dishwasher Meter ❑over 100 amps
eCertitietl copy is nereby lurnishetl. Dryers �Gas ❑Electric Sub Panel
Certifietl copy is iiletl with the city Builtling Division. Bathtubs Sewer Connection
Date Applicani_ Fan Motors�0.1HP�1'h-8
E%EMPTION FROM WORKERS' COMPENSATION DECLARATION Clefifiefs Solar Coll¢Ctors
(Thissectlon naeC not be completetl If the permit is for one huntlred ($100) or Dishwa5he� SOlar Piping F�A•�� Inc. Solar �9-75 HP 016�75+
less)
1 certity lhat in lh¢ Perto�mance of trye wo�k tor whlCh this pe�m�t is i55uetl I Fi%tU�¢5 Microwave
snall not employ any person in any m;I ne[ so yz to becoma subject to t�e Drinking Fountains Solar Tank
Worker C� m�pe9�a� ion Laws of Califp�yl:�Rl�/ .
Date �J�"i-127—Si9nature i��K "'4.- Floor Drains Swimming Pool w/Spa Device Boxes Pole Light
NOTICE: If, after making this tleclaration, you shoultl bec me subjett to the OutlCts
Workers' Compensation prOvisions ot tne Labo� Cotle, y0u must forthwith FIOO�Si�kS U�inal Range
comply with such provisions or this permlt shall be tleemetl revoketl.
CONSTRUCTION LENDING AGENCV GasServiee Outlets Wat¢rCloSet SwitchCS Sign
1 hereby allirm tnat tnere ii a construction IenOing a9ency for the performance G2rba e Di osal
o/ N¢ wo�k to� which thls permit i5 i55uetl ($ection 3097 Civ. CJ Int2lC2Pt0�5 Wd[Cf HEdtE� 9 � Standing Sections
LenCer's Name
Lender's ndaress Kitchen Sink Water Service Generator �0�5 KW �5-15 KW Trash Compactor
OWNERBUILDER DECLARATION _
I heleby dtfitm Ihat I am exempt f/om the Conlldct0!'S UcenS¢ Law tor the LdVdtOli¢5 AUtO�W85h
tollowing reason (Settion 7031.5 Bugi�ess antl Professional Cotle: Any city or
county which requirez a pe�mit t0 cohstrUct, alter, irtlprove, tlGmolish or repai� P—Tldp Laundry Treys -
any structure, prlor to its issuance, also requlres Ihe applican[ for sucM1 permit
f0 tile a Signetl statement that he/sh¢ is Ilcen58tl pu�suan[ to [ne prOvlsion5 of Roof �rains
[he Contraclor's License Law (Chap[er 9(commencin9 with Section 7000) of
Division 3 01 [M1e Bu5ine55 antl Profe55ions Cotl¢) ol that he/sh¢ is exempt RelnSp¢CtiOn Fe8 $75 155118 F88 $ 3
therefrom antl the basis tor the allegytl exemp[lon. Any violation o� Section •
7031.5 by any ap0litant tor a pe�mit Subjects Iha applicant to a civil
Qe,j�alty o/ not more than tive huntlrea tloiiars 15500). DEVELOPMENT SERVICES REDUIREMENTS:
VJ`I, as owner of the property ' ' Reinspection Fee $15 Issue Fee $ 3
2oning Approved By Date
eo.wpert�SN� will tlo tne work, antl �ne structura i5 not intentletl or ofteretl
to� sale (Seclion 7044, eusiness antl Grotessional Cotle: The Coniractor's MECHANICAL FEES Building APPraved By Date__/-[.�Z
License Law tloes nol apPly to an owner of a property who bulltls or improves q ��ption Issued B
thereon, antl who tloes such work himselt/herselt or ttvough hls or her own PP Y Dat
employees, provitletl mat zucn impro�aments aro not Intentlea or otfer<tl for Boiler Hood or Type I ❑
sale. If, however, the builtlin9 or improvement I5 soltl wlthin one year of com- �nopy Type I I ❑ SUMMq(3V pE FEES
plelion, [he owner will have the burqen Of prOving he/She tliG not bulltl or im- Duct - Under Ground �(/ �7�
prova for tne puroose ot sale). BUILDING PERMIT $_i/�YL SMIP $ �S�
❑ I, as owner ot the property, am exclusively contracting with Iicensetl con- Duct- Structural RCfrigeratiOn SysLEm
tractorsto mnstrucl the project (Section 7044, Buziness anA Professions Cotle: PLAN CHECK $ PERMIT
The ConVactor's License law tloes not apply to an owner of properry who Duc[- Ventilatin9 00.100,000 BTU ❑100,000 BTU PLUMBING $ �SSUANCE $
builtls or imoroves mmeon. antl whp contra<ts for such orolects with a con- ENERGY P.C. $
vactor(sl hcense pureuane m me Contractors Llcense Law). I am aware mat Exhaust SyStem ❑ Multiple ❑ System Repair/Alteration P�P.N CHECK 25% $
proof of tneir Worker's Compensation Insurance snoultl be proWtlea to me. ELECTRICAL $ GRADING $
❑ I am enemo� untler Section— e. & P. C. for this reason Firepl/Fact. BIL ICBO dk Fire Dampers MICROFILM $
PLAN CHECK 50% $ ^
Dt �..._ HeatingSystem&Ducting Registers ' MECHANICAL $ TOTALFEE $�9.SCJ
I hereby certlfyS�tnat I nave reatl tqis application tl state tnat tne above ❑0.100,000 BTU 0100,OOOBT P�qN CHECK 25% $
IMormation is correcL I agree to comply wrtn all city antl county ortlinances
antl state laws relating to builtling cOnztructlon, anU hereby authorize repre- -
santd[ives of tM1is Uty o enter upan th¢ dbOve-mentioned O�aperty fo�
Inip¢CtiOn pulp05
Si9nature �. ��� � Date ����� ' ,,, . - � -
orivers' License or SS � - - Reinspection Fee $15 laue Fee $ 3 _ _ • �I _ . _ .
,.� - ' '. _. _, ._�._. .. ._� .
0865-46, rev. 5/BB White - Builtling; Canary - Applicant: Pink � Accountin9: Goltlenrotl - ASsessor
. �
, , CONSTRUCTION AND PLANNING POOL & �P.FA
Date Inspector Date Inspector
� APPROVALS Permit# APPROVALS Permit#
7. Tempo�ary Electrical Serviceor Pole ,' 52. Pool & Equipment Location
2. Soil Pipe�Undrgrnd. 53. Steel Reinforcement �.
�
3. Electrical Conduit Utility-Undrgrnd. 54. Forms � �
4� �lectrical Conduit-Undrgrnd. 55. Electrical Bonding � j
5.� Steel Reinfo�cement , 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE i'.
�
7. Footings ' '� 58. Electrical Conduit-Undrgmd. �
8: Foundation , 59. Gas Pipe, O Undrgmd�., Test �'
P
9. Water Pipe-Undrgrnd. ! 60. Backwash Lines, P-Trap, O Undrgrnd. ' '
10. Structural Floor System � 61. APPROVAL TO DECK I �
11. Property Sewer Line & House Connection . 62. Backwash & Receptor-Final
12. Sewer Cap � 63. Heater & Vent-Final � '
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final � e,
15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough Electric Wiring 67. Fencing & Access Approval
17� Rough Wiring Sign . 68. APPROVED FOR PLASTERING
1S. Rough Electrical-T Bar Ceiling 69. POOL/SPASYSTEMS FINAL •
1,9:� Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20:,Rough FactorY Fireplace APPROVALS Permit #
21. Ducts, in Structure 70. Underground Hydro
22. Oucts, Ventilating 71. Product Piping �Gas ❑Oil
23. Gas Pipe-Rough &aTest 72. Underground Flush
24. Roof Framing � 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing '• 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL .
29. Insuletion 78. FIRE PREV. FINAL
30. Drywall Nailing •• HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coa�. •^ 79. FINAL INSPECTION
�� .
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heating & Air Conditioning p P �
35. Final Gas Pipe-Test /
36. Hood or CanOPY �
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. Solar pomest�c-Final
42. Backflow Preventer .
43. Backflow Irrigation .
44. Landscape Irrigation System
45. Sound Attenuation �
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING � ; ��; ��
48. Special Requirements Completed
49. Electric Release to Edison .
50. Gas Release to Southern California Gas Co �
51. CERTIFICA7E OF OCCUPANCY � . -
No. Date •
CITY OF COSTA MESA
BUILDING DIVISION
OWNER�UILDER VERIFICATION
A dtr a oountV. M4+ieh k tpuind to pivc notioe purswnt to Section 19630. dull atuch to wah
nOtict, snd. a a cOndition proa6ent tn iauiny i buiidity permit, rtquire tht COrtfpbti0n Md nquire
the rscurn ot, �n owner-0uilder verifintion. . .
Anention Property Ovma:
qn ownerbuifder' buiidinp permit Ms b�m �pplied fa in your eume u�d barinp your �ipnrture.
ikau comptete �nd ratum thit in(orm�tion in the �nvelope povidad �t your urti�st opportunity
to �roid unneceuary delay in processinp ud ksuinp your buildinp permit. No buildinp permit will be
issued until this verifiotion ii roxived.
1. 1 pertonalfY P�+n to provide tM rm)or Irbor �nd rtrtttials tot CoroVuetioti ot tfie poposed
property improvement. �-Yec D No
2. 1(fuveAur� "�"'�' sfpnsd �n appli�ation ta a bufldinp permit for the
ProDOKd work.
3. f Mve oonmacd with the fottowirg person (fi Lso-provide the propored oonmuction:
W tne ��
Addre:s ''� -
4. 1 pl�n Lp provide portiorn of the work, 'nd tf+e owinp ooadirutq,
wperviu �nd D�ovide the major .
Name
Address
Ohone 1 1 Contrattor't 13e. �
5 1 will povide wme of the vwrtc but 1 fure oontracted (hi � followin0 persoex to provide
the work irdirated:
N,n,� nea..a / nwro T�a-a work
1 Aereby tHirm tfiat I hav� noeived a aopy ot the {ntorrtvtion set forth in Section 19830 of tlx
Sute of Califomia Hukh �nd Srfety Code erW luw eompined the �bove infomution to the best oi my
perscmai knowl�dye, in complimce wiM thu Sba law. .
SGned: - 7��'°°-�°uC"�'i"' Da��` �-- �.' Fs-�'i
Nsme: /-� � G' f? � � f� � l-�k c-R-
(Rinted.or Typed)
C.D.L �or S.S. � ' �'
c..� �w:.c 754-5273
�
R 3722 ' 13�.�� �
� --J
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 9f7 COBTA ME9A. CALIFORNIA
For Applicanf fo Fill In Compleiely
BUILDING 3252 NEBRASKA LANE
ADDRE68
C05TA MESA. CALIFORNIA
OWNER K$c E DEVELOPMENT CO.�INC.
MAIL
Beach No:t41 6-
TEL.
Placentia Ave.
i;c".TNo. 61195 No: Mi 6-3z27
s�=E 7ox99,oz IRREG INO.OPa��s. o
OF LOT NOW ON LOT
use oF None
EXISTING BLDG
SiiBACK LINE PpOM � �
cexren or erwaer O REAR VARD ZO
/ �J �
SIDE YARD I LEF( RIGHT �7
DESGRIPTION OF WORK
.,�.., � X ��„r�ver,..., � ��e.,.,,.,,.., �
F % �
� STORIES
? WOOD SHINGLES
RING
�E P� ORMED
esi ence and
FEE RECEIVED
�� OCT 241960
FINANCE DEPT.
APPLICATIc�YF� �GtS�rMESA
BUILDING
For Office Use Only
RHCHIPT NO. � P�IIQA)IT.[{O_
o�re �Beuco
GOSTA MESA, CALIFORNIA
FIRE
ZONE
APPROVED
ZONING
ZONE I NO. OP I IIeE OF N¢W / �
R�1 PLAN9 2 BIIILDING W 8t't
180�L _ . _ _ — . ..�..�
vaRos
APPROVED
IC8NT6R LINB BT.1
APPROVED
PLAN 7-B
1 H¢ReBV ACNNOW�DOB THAT I HAVE RGD TM18 �PPLIGTION }N6 AMOUNT BHOWN UNOlR VALUATION IB IOM TH6
AND BTATH THAT YM8 I�BOVH �B COH AND AOR88 TO COM• pUliP096 OP E9TABLI6HING A PEPMIT FHE ONLY.
PLY WITH ALL Cll�" OfiDiNANC88 .� TH W8 RBOULATINO
Bu��olNo CONeTVU x. VALUATION
�
81GNA7URE OF dp PERMIT FEE $ �
PERMITfE v
$ � ��� � PLAN CHEGK $ �C
AUTHORIZED AGEN7 (—��_