HomeMy WebLinkAbout2040 NATIONAL AVE - Building Permits\ . -• CITY OF COSTA MESA • � � � • . • -
BIIILD/NG DIVIS./ON , �
77 FAIR DRIVE, COSTA MESA, CA 92626 • Q14) 754-5273 • Fax Q14) 754-4856 • wv+w.ci.costa-mesa.ca.`us
FOR INSPECTIONS CALL: (714) 754-5626 � _
PERMIT NUMBER: P,.1'0-OOOfi6
PERMIT TYPE PLUM
APN: 42249211
JOB ADDRESS: 2040
Vicinity: INTERIOR OF H
SCOP.E OF WORK: REP
TUB,2 LAVS, 1 SHOWER,
OWNER: PEARCE,
PHONE: ''
APPLICANT: PEARCE.
PHONE:
CONTRACTOR: OW
Address: ��
City/State:
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ARCHITECT:�
ENGINEER: �
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STATUS:
DATE ISSUED:
-- ISSUED BY:
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ISSUED
05124)2010
BE �
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AS AND',]iKITCHEN. WORK INCLUDES 1
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��ONTINENTAL AVE;�{�,
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;ONTINENTAL"�AVE �`e �fl, ' ��
A MESA CA ", " ���� 4k�; � �
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PLAN�CHECK FEE ,� F^ �, ti ,.$0 00,,;�;�:-`
PERMIT FEE g`'J�' {J� r �� i� z�� S82 30 �" .
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TOTAL FEES h ' �_ t«:� --' $82.30
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aATE: `` 1
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.
C OEN. INSPEL110NTYPE Or1T INTITIALS CODEI ,INSPECTIONTVPE �ATE IN11TIpL5
76t6 Fixed System Final Fire Prevention � 206 Final Mechanical
1266 Pool Spa Final � 208 Final Plumbing '
200 Final Re-Roof 210 Final Electncal '
201 Pinal,9bck/Retaining Wall ' 212 Final Fire Prevention ,
�'.. . .
202 �, Final Factory Fire Place � .220 Final Planning Appmval
203 Final Sign� � — ' � 222 Final Site '
204 Final Demolition 250 Final Building/Occupancy `
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WORKERS' COMPENSATION DECLARATION:
I hereby aHirm under penalty of perjury one of the lollowing tleclarations:
,�'Ovmer ID verifed by drive•ense. Ves ❑ No
�i Driver's License No. Expires:
❑ I have and will maintain a certifcate of consent to self-Insure for workers"
compensation, as provided (or by section 3700 0(. the Labor Cotle, !or the �
peRormance of the vrork for which lhis permit is issued. ' �
❑ I have and will maintain wnrkers' compensa�ion insu2ncer as required by �
section 3700 of the labor Code, for the peAormance o( Ihe work fa which this
pertnil is issued. My vrorkers' compensation Insurance carrier and policy
number are:
Carrier:
(This setlon neetlnot oe wmpletetl nMe peimrt B valued al ona hundie0 �llars (Sf 00) w less.)
Policy Number:
❑ I certify iha[ in lhe performance of the vrork !or which this permit is
issued, I shall not employ any person in any manner so as to become subject
to the workers' compensation laws o( Calitomia, and agree thal i( I should
become subject to the workers' compensation provisions of Section 3700 of
the Labor Cotle, I shall (orthwith comply with ihese provisions.
Applicanl's Signalure
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO 'CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
(5100,000), 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 that I am licensed under provisions of Chapter 9(commencing
with Section 7000) o( Division 3 0( the Business antl Professions Cotle, an0
my license is in WII force and effect.
Lic. # _ Class #
Gomraclor's SignaWre
CONSTRUCTION LENDING AGENCY:
❑ I hereby affmn that there is a constmction lentling agency for the
peRortnance of the work ta wfiich Ihis pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Adtlress:
OW NER•BUILDER DECLARATIONS:
I hereby affirm Ihat under penalty of perjury Ihat I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5.
Business and Prolessions Cotle: Any cily or county which requires a permit to
construct, alter, impmve, tlemolish, or repair any sWcture, pnor to its
issuance. also requires the applicant for such permit to file a signed statement
Ihat he or she is licensetl pursuant to the provisions of Ihe Contractors
License Law (Chapler 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or ihat he or she is exempt iherefrom and
�he basis for the allegeC exemption. Any violation o1 Section 7031:5 by any
applican[ for a permit subjecls the applicant to a civil penalry of nol more Ihan
fv hundretl tlollars ($500).): '�� ,
� I, as ovmer of lhe property, or my employees with wages as their sole
compensation, WILL DO THE WORK, antl the structure is not intended or
oflered for sale (Sec. 7044, Business and Professions Code: The CoNractors
License Law does nol apply to an owner of property who builds or improves
thereon, and who does such vrork himself or herself or through his or her own
employees, provided Ihat such improvements are not intended or offered for
sale. f, however, the building or impmvement is sold within one year of
com etion, the ovmer-builder vnll have Ihe burden of provinq that he or she
did ot build or improve for purpose of sale.). ,
I, as owner of the property, am EXCLUSIVEI:Y CONTRACTING WITH
UCENSED CONTRAC70RS to consiruct Ihe projecl (Sec. 7044, Business and
Profe3sions Code: The contractors License Law does not apply to an owner of
propeny who builds or improves thereon, and who contracts for such project with
a contracta(s) license pursuant to the Contractors License Laws.).
I am exempt under sec. �
Business and Professions Code /or this reason:
I'� Lj Z fL / �O
' Signawre � Da�e �
005➢-06 (3/0])
\
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Verificalion of Ovmership by (rype of dowment, i.e. - property taic bill or deed):.
. �
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DIVISION OF INDUS7RIAL SAFETY PERMIT CERTIFICATION: �
❑ I hereby certAy that no excavation frve (5) or more feet in depth in[o wfiich a
person is required to descentl, will be made in connection with work authonzed
by lhis permit, and that no building strucWre, scaHolding, (alsevrork, a demolition
or dismantling thereof, will De more [han Ihitly-six (36) feet high. (Chap. 32, Grp
2, M 2, Sec. 341, Title 8, Cali(omia Atlminist2tive Code).
❑ As ovmer-builder, I will nol employ anyone ro do vrork which vrould
require a permit from the Division oi Indus�rial Safety, as notetl above, unless
such person has a permit to do such work from the division.
ApplicaM's SignaWre Dale
Division of Industrial Safety Permit Number. _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or fulure building occupant neetl to file and
cehi(y a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No , �• .
(Section 25505 of the Califomia Health antl Safety Code requires, with some
exceptions, that a Business Plan be filed vn[h the Costa Mesa Fire
DepartmeN by every business which has at any one time dunng a reported
year a quantiry of hazardous materials equal to or greater than a weight of
500 pountls, or a volume of 55 gallons, or 200 cubic feet o! compressed gas
at standard IemperaNre and pressure). �
2. Does or will the applicant or present or tuNre building occupant need to fle
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Cali(ornia Health antl Safery Code, with some
exceplions, requires registration vnth the Costa Mesa Fire Department by
each business which at any one time has on hantl a quantiry of awtely
hazartlous ma[erials equal to or greater ihan a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at s[andard
temperaWre and pressure). , -
3. Does or will the applicant or present or fuWre builtling occupant need lo
prepare an RMPP (Risk Management and Preven[ion Program for acutely
hazartlous materials)? ❑ Ves ❑ No
(Section 25534 of the California Health and Safe[y Code provides ihat the
Costa Mesa Fire Department may require the preparation, certifcation antl
filing with the Fire Department of an RMPP by businesses which are required
to register awtely hazardoUs matenals wilh the Fire DepaM1menl.
4. I! an RMPP is presently requireQ has Section 25534 of the Califomia
Health and Safety Code been fully complied with? � Yes ❑ No
5. Does or will Ihe applicant or present or (uture building occupant require (or
the vrork which is the subject of this application a permit for such wnstruction
or motlification from the South Coast Air Qualiry Managemenl District or (rom
any other air pollution control distnct or agency? ❑ Yes ❑ No
(Section 658502 of the Califomia Govemment Cotle requires that the requestetl
infwmation be (umished on appliwtions fa non-residential builtling pertnits).
6. Will any part of the (aciliry ro be construcled under this permit be within
` 7000 (eet from the outer boundaries of a school? ❑ Yes ❑ No
Q('yes", the facility must meet the requirement of Sections 25534 and 42303
of the Calilomia Health antl Safery CoOe).
7. If a pertnit (rom the South Coast Air Quality Management DisVict or other
air pollution wntrol district or agency is required for the wnrk which is the
subject of this application, have all of lhe disclosures prescribed by Califomia
Health antl Safety Code Section 42303 been made? ❑ Yes ❑ No
� 8. (If'yes", attach certificate of compliance from the appropnate air pollution
control oKcer).
CERTIFICATE'OF COMPLIANCE: I certify that under penalty of perjury the
infortnation given above is conect. I agree to comply with all state�laws and
city ortlinances regartling Hazartlous Materials and Emissions.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:- F
certity under penalty ot perjury that I have read this application and state that
the information given is correcL I agree b comply vrith all state laws and city
ordinances rela�ing to builtling cons[ruction, and authonze represenWtives o(
the City of Costa Mesa to enter upon Ihe above-described property tor
inspection purposes. I a not to occupy or allow occupancy of any building
au�hor' e by ' per, un final ins✓e� . � 2 �
iSgnaWre�Legalpwner�s) Oale �O
AnOlor Aul�orrze0 AOd����
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Costa Mesa
City of Costa �l�lesa BuiCding l�ivision
77 Fair Drive, Costa Mesa, CA 92626
714-754-5273 / Fax 714-754-4856
OWNER BUILDER VERIFICATION
Permit #
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 been submitted in your name listing yourself as the builder of the
propertyimprovementsspecifiedat 2'��fa .UA7/DA/ AC ,r1[/r"
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.
rnrtia! 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 fnancial risk for any
injuries sustained by an unlicensed person and his or her employees while working on my property. My
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.
2. I understand building permits are not required to be signed by property owners unless they are
esponsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
�3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that
ay protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his
�or her me instead of my own.
' I understand Contractors are required by law to be licensed and bonded in California and to list their
license numbers on permits and contracts. " _
I understand if I employ or other,vise engage any persons, other than California licensed Contractors,
d 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
law�y 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 pertormed under contract with a licensed general building Contractor.
3148-30 CALBO Jan 1, 2009 OB Packet template 1 of 2
�I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liab�e
for any financial or .personal injuries sustained by any subsequent owner(s) that result from. any latent
construction defects in the workmanship or materials.
� understand I may'obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the Uniteq 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
about licensed contractors.
10. I am aware of and cohsent 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:
�. I agree that, as the p8rty legally and financially responsible for this proposed construction activity, I will
abide b all applicable laws and requirements that govern Owner-Builders as well as employers.
12. I agree to notify the igsuer of this form immediately of any additions, deletions, or changes to any of the�
info ation 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 propeRy, 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 nof 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 propeRy owner's
driver's license, form notarization, or other verification acceptable to the agency is required to tie:
presented when the permit is issued to verify e property owner's signature.
Signature of property owner ��l�Q C Date: Z� ��
Note: The /ollowing 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, si9n, and file the documents
necessary to obtain an Owner-Builder Permit for my project.
Scope of Construction Project (or Description of Work): ��i1/%7�/� �/I�UN% �%Lt/,NI/j/d�/r
Project Location or Address: Zby� /yj�j/ jJ�� fJ(/�
Name of Authorized Agent:
Address of Authorized Agent:
Tel No��/ Z/6 3 ���/
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 ceRify its accuracy. Note: A copy of the owner's driver's license, form
notarization, or other veri(icatibn acceptable to the agency is required to be presented when the permit is issued
to verify the propeRy owner's signature.
Property Owner's Signature:
Date:
3148-30 CALBO Jan 1, 2009 06 Packet template 2 Of 2
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' • • • CITY OF COSTA MESA
REFUND REQUEST FORM
r'rom: ❑ Finance
�uilding Safep�
❑ Planning
[] Public Services
❑ Community Services
❑ Other
Account Wntl � � Orc
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Vendor #:
Permit#" pl�'bG(�Q�___
Amount 5_ �Q5•�y
DaEe: ll��� � l�
Signature
Name and address of aoplicant ,nCl(/G� �G �2 <C �
Zo Z 3 '�D ,�,1 7!ov ��T.� L. A�U �
Phone:
REASONFOR REFUND:
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APPROVALS:
Finance:
Ciry Manager _
z<o,-z: Mw or+ur+E
ORANGE COUNTY BUILDING DEPARTMENT ; APPLICATION POR PERM17
' ' �636 NoAh Broadway, � �• . ' •
•. " _' $ANTA ANA..CALIFORNIA ` - � `- _ �.�'�_L'�`�'�'�_' --�--�'
� FOR APpLICANT TO FILL IN �'- r—FOR OF.F.ICE..USE_ONLY��,� �
' , �' RECEIPT NO: PERMItLNO.�, _
A�DRE55 �'386-National Ave� i,. �� 43�. � I Sv 2n� ,3 •�
SCHOOL DIST ' ' ' ��
OR TOWN COSti$' MeS$ � ' RECENED BY � DATE�ftEG'D. . DATE ISSIiED
c"RosssT. M�nrovia St_ °�?�� a�I�/—°�' � 3 I�'�r^"53
BUILDING' "/`J�U�� �� � .�/� .j� � �/f 1
OWNER Mohawk��Homea Ti�ii'i. ADORE55 . "YTJ�tI� -/- I(�J�(���(,/L 1
MAIL � ' SCHOOL DI6T. +� � � '
nooaess 9363 Wilahire Blvd. pRITOWN � �iti—a�i�, �, it -
��TY . Be ve r1Y H1118 . No�.'R 54361 �Rossssr. i �7� My� ' (
ARCHITECT R LIC. ZONE j NO. OF1 TYP GROUP i
ENGINEER �ain� & McKerractc�r IlA / $ I �PLANS � I. '� " I �f�� .
}/�1 t
ADORE552110 E,Walnut-Paeadena BypROVEDi�(� �./� � �DATE `�'.S!
' dJ�d 7J-.
'CONTRACTOR N2�OT`t -Vlstst+o �135882 .- � ' (
,, � . CORRECTION$ i ' �.�, .
ADDRE� `� B � . . ' •
1 � d�y .,. j , y
LEGAL LOT . � • ,�" � \
DESCRIPTION I NO. 21 BLOCK I TRACTI.%ZZ � �� � ; � '
� �.
IATTACH METES 8 @pUNDS) - ' + I :., ..'�
n NO. OF BLDGS. � F � � �� - �y
SIZE OF LOT lO X ZZO I NOW'ON LOT 'O '`.��j.. ;'
USE OF I NO. OF I NO. OF � ' I ' I-•" '
'EXISTING BLDG. - FnN�ueS ROOMS � ,�-r�— —.--<-+. , �_
SETBACK LINE FROM: REAR YARD �t)p �' ~
CENTEF OF STREET 5O PY. _ SIDE YARD 4.� �. - � -
� , `
" DESCRIPTION OF WORK � . • p
' -'v:ai,.n��.��:c..,�� :. . �,
•NEW .IA I�ALTERATION' I �,I� ADOIT�ON I � . . , ' � � iZ _ ,
'. ' �.. .
' REPA�R I.l- I MOVING I' I' �EMOLISH' I •.y��u+�. cq,/UuieteJ 1,w.!+-,.udw-.v.uiw r, a.
_ ....[4.'3.�.1 _.......:�� .i 4.' ....�i�...4�.c..:...�
BUIIDIf�G�� NO. OF, - . _ . . • -
�SIZE ,�LZO BQ:�tRQOMS Fj ."STORIES� , , . -" � . _ �
�EXTERIOR;WALL ROOF �� pmDO ' . , _ ' �
COVERING " SYiISCC� COVERING Sh1 nal a � � ,. - - __ . .. ��':�:. �
� USE OF NEW - � - .- , . - .
BUILOING Residence-Att. Carport � _ � � ` .. � -
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� ' � APPROVALS �
- - � - „FOUNOATION:� LOCATION IN$�CTOR ' �•. DATE'�
1 HEREBY ACKNOWLEDGE THAT 1 HAVE, READ THIS FORMS, MATERIALS, // 'j6 �
APPLICATION AND STATE THAT THE ABOVE'IS.CORRECT� UNDER-PINNING .Y ,J
� FRAME: FIRE STOPS, .
AND-AGREE TO COMPLY WITH ALC COUNTY OROINANCES` �' i33
AND STATE LAWS FpGULATING BUILDING GONSTRUCTION. �BRACING, BOLTS
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