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Home My WebLink About1860 IOWA ST - Building Permits ' p- / CITY OF COSTA MESA 4, BUILDING DIVISION F ;Mirk; I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT likrbabiaaanali"lt PO4-00360 (714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 1856 IOWA ST Status: ISSUED Suite No Applied: 05/25/2004 Issued: 05/25/2004 Vicinity: �� ISSUED BY: Parcel Nunmber: 13904336 Applicant: SZABO, KEVIN Address: 2737 S CRODDY STE D Phone: (714)241-1414 SANTA ANA,CA Zip: 92704 • • Owner: VOCKE, JAMES G,TR Address 3257 DAKOTA AVE Phone: COSTA MESA,CA Zip: 92626-2241 Contractor: COAST ROOTER PLUMBING HT_ G & NC Address: 2737 S CRODDY STE D Phone: (714)241-1414 SANTA ANA,CA Zip: 92704 License: 529127 • Arch / Eng : Address: • Phone: Zip: License: SCOPE OF PERMIT CHANGE OUT WATER HEATER FEE SUMMARY • AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect - $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 - Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0 Drain, Roof $0.00 0 - Shower $0.00 0 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2448-48(8'00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: O 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 end 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: ST ATE FO FAD Policy Number: ''-ICO SSS- ZOp'), (This section need not be'completed If the permit is valued at one hundred dollars($100)or less.) IX I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Ca'fomia,an e that I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these pro I ons.- ` / Applicant Signature: ice! Date: S-- ZS-0 4 WARNING:FAILURE TO SECURE W S'CO SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(comm ncing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.g Lic.atu e S7_917ii Classat : q "Contractor's - Signature: Date: S '7i S'04 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation.WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.), ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). O I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the 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? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 8 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? 0 Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SI at e Of eget Owner(s) Date 2-S"-- e 1 A Authorized Applicant Date CODE A INSPECTION TYPE PAIS INTTTIALS CODE II INSPECTION TYPE PAIS RIIID.L$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical �/ ��/(K/ry�,/',� 1266 Pool Spa Final 208 Final Plumbing , ' t{�� V . 200 Final Re-Roof 210 Final Electrical _ 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. /1' ' ' \, CITY O '-74:TA-MESA C, NSTRUCTION PERMIT PERMITNO. ACT L NO. UNIT NO. tt.Prolep, .dress %I�.Y ! Lu✓9. c�/� a234/F1SX,CT •�" 7,1' acr TYPEOF CONSTRUCTION U NEW ADD U ALTERATION U REPAIR Owner's nAppis Nameailing_A ss , / C ��4 Phone / / Il A.P.# ' 3q - ( p� - ao Zone VOL _I •�[/- r �/ ❑ CONVERSION ❑ DEMOLISH OTHER gai AddressName( L777JL.1>iJJ'o DESCRIPTION OF WORK/USE OF BLDG. Address /d a 6wo /� �S/A/L/C7a� •S Main Building:+f"Qrit- Accessory`Building: reixr ��II E ^ / 1.1ti Z Arch/Eng. License No. TYPE OF PERMIT .CJ GRADING L�FOUNDATION STRUCTURAL T Front Cf 1 0 Address /•� t ❑ TENANT /ELECTRICAL PLUMBING ❑ MECHANICAL B Rear a ia' N r Contractor's Name_10 Phone 4C/ fes ❑ OTHER ` A �i Address(mailing) PROJECT DESCRIPTION SQ.�F/,7. 59.1 9-7 OCCUPANCY Z % C Right 51 I R/ f N • . - - C ON STRUCTION TYPE V L VALUATION$ 26/ 7DO $ Left 13.5 .4.0eicn. - 39 R City License No. ZONE -. ' GRADING CU.YDS. ACRES v .1 LICENSED CONTRACTOR DECLARATION �-s Ping. Ref.# Parking Req,/Provided E I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: .QC• a r/5•..• ' _ y, •i,r"'`'� v., Planning Notes AULD Wit SYGIdAL Ge(DIRE1YIEIVTS M with section 7000) of Division 3 of the Business and Professions Code, and ---n ✓ Ca(,� v`.A.L• �) T my license is in full force and effect. a 7/',isn f kta irk ita 7r r n �-r•:N ri-17 r IO et License Class License No. fw• `s-" v-�+'.1-��aw�•-•�� —(�)(�L�-�K- S Date Signature - PLUMBING FEES f_ WORKERS' COMPENSATION DECLARATION • / gar Sink / Showers ELECTRICAL FEES 'hereby affirm that I have a certificateto of consent to self-insure or a certificate . ✓ OJ • Workers' Compensation insurance, or a certified copy thereof (Section Backflow Preventer Service Sink ,800, Lab. C.) Automatic Washer Transformer 0 15-50 KW Policy No. ,Company - _- - Backflow Irrigation Sewer Cap Construction Pole Sub. 0 50+ KW 8 Certified copy is hereby furnished. • . Certified copy is filed with the City Building Division. Bathtubs Sewer Connection Cooking Unit Meter ❑up to 100 amps Date Applicant EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors Dishwasher Meter Cover 100 amps (This section need not be completed i the permit s for •ne hundred ($100)or less). i Dishwasher Solar Piping Dryers ❑Gas ❑Electric Sub Panel I certify that-in the performance of f•r whL his permit is issued, I shall not ploy any person in any . ecome subject to the Drinking Fountains Solar Tank Fan / Workers' I1nn pe lion Laws of Calif• •I• - Motors ❑0-1 HP ❑1X-B. OV Date' /(f Signature - Floor Drains Swimmin Pool w/S a7 9 P P.A.U.FAUInc.Solar 09-15 HP 016-15+ NOTICE:If,if er making this declaratio , y•u should become subject to the — - Workers' Co pensation provisions of t e LLLLLL��b��bor Code, you must forthwith Floor Sinks Urinal <Fixtures Microwave / comply with such provisions or this per it shall be deemed revoked. - ! Ok+ CONSTRUCTION LENDING AGENC II.. Gas Service Outlets Water Closet 2.42-d Device Boxes I hereby affirm that there is a constructio le ding agency for the performance o-si Pole Light of the work for which this permit is issuetl (Section 3097, Civ. C.) - Interceptors Water Heater Outlets Range Lender's Name 13 9 2 tro Lender's Address Kitchen Sink - Water Service F))O Switches Sign 2 - q OWNER BUILDER DECLARATION Pa I hereby affirm that l'am exempt from the Contractor's License Law for the / Lavatories • Auto-Wash •'� _ following reason (Section 7031.5,Buslness and Professional Code: Any city or Garbage.Disposal Standing Sections county which requires a permit to,con struct,alter,improve,demolish or repair P-Trap Laundry Trays Generator ❑0-5 KW❑5-15 KW any structure, prior to,its issuance, also requires the applicant for such permit - - Trash Compactor to file a signed statement that he/she is licensed pursuant to the provisions of • • Roof Drains - the Contractor's License Law(Chapter 9(commencing with Section 7000)of ' -- ' ' -Division 3 of the Business and Professions Code) or that he/she is exempt :<*herefrom 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 'I;pendlty of not more than five hundred dollars($500). I - I, as owner of the property or my employees with wages as their sole Reinspection Fee If $15 Issue Fee $ 3 I.compensation, will do the work, and the structure is not intended or offered Reinspection Fee I $15 Issue Fee $ 3 for sale (Section 7044. Business and Professional Code: The Contractor's MECHANICAL FEES - ) License Law does not apply to an owner of a property who builds or Improves thereon, and who does such work himself/herself or through his or her own DEVELOPMENT SERVICES REQUIREM S: employees, provided that such improvements are not intended or offered for Boiler Hood or Type I ❑ 1 //a /D/r �• Q� , sale. If, however, the building or Improvement is sold within one year of corn- Canopy Type II ❑ Zoning Approved By hA�� .C.��Y�`�)� Data (�7 • pre the owner will have the burden of proving he/she did not build or Im- Duct-Under Ground Building Approved By Date forprove a purpose of sale). ' - ❑ I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System Application Issued By Date tractors to construct the project (Section 7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00-100,000 BTU 0100,000 BTU SUMMARY OF FEES builds or improves thereon, and who contracts for such projects with a con- •-- tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System ❑ Multiple❑ System Repair/Alteration BUILDING PERMIT $ Ilg•6-0 SMTP $ I. B6 proof of their Worker's CompeSe,ion�iq�ran{ should be Provided to me. _ PLAN CHECK $ I I� 61 PERMIT ❑ I am ex•mpt under Section \t(� /11 1 / B. & P.C.for this reason Firepl/Fact,Bit. ICBG# Fire Dampers ISSUANCE $ } I I / PLUMBING $ ODDate _- 1,44.7..._ O ne \ V c f Hung System& Ducting Registers - z(Qv ENERGY P.C. $ 7 PLAN CHECK 25% $ -L•OU I hereby , rtify/that I hay rto co ply application and state that the above ry'/ 210-100,000 BTU 0100,000 BT GRADING $ - information(s\correddAleer to co}npl✓ with all city and county ordinances ," ELECTRICAL $ 9,6v and state laws :' a 1¢q 5' Udine onstruction, and hereby authorize repre- sentatives o' t t ter on the above-mentioned prop rty for - / l� �{7 Inspection pu ••s: .t� - /�/! 1 MECHANICAL $ 7. oD TOTAL FEE $ �+�7 t 1 y Signature/ • Date (r/J Reinspection Fee I $15 Issue Fee $ 3 PLAN CHECK 25% $ /. O() Drivers' License or S t - CMF 0865-46,rev. 10 '4 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor IA Pr • CONSTRUCTION AND PLANNING POOL & SPA APPROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 'f$(fI7 /4,9 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms . 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UF ER Grnd. fie/ 94 57. APPROVAL TO COVER-GUNITE 7. Footings a S's•1EtC ] D4 58. Electrical Conduit-Undrgrnd. B. Foundation - . . 59. Gas Pipe, 0 Undrgrnd.,Test . 9. Water Pipe-Undrgrnd. // (,8 60. Backwash Lines, P-Trap, 0 Undrgrnd. 1i.!(� 10. Structural Floor System ) U61. APPROVAL TO DECK 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 YM///Z Lr) 65. Electrical-Final • 15. Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring Miry r�r" 67. Fencing & Access Approval 17. Rough Wiring Sign [ / 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace APPROVALS Permit# _ 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing - - 73. Undergrnd.Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat • . 75. Dry Chemical I 27. Frame and Flashing ScG pert_ 76. bry Standpipe . 28. Lathing & Siding '77. FIXED SYSTEM FINAL 29. Insulation S42.a- N0r2_. - 78. FIRE PREV. FINAL 30. Drywall Nailing 4/w /nI4 i(j HEALTH DEPT. REQUIREMENT • 31. Plaster Brown Coat / iii 24t1 6,-/ 79. FINAL INSPECTION . . 32. Electrical Power Meter-Final J 80.'FOOD CERTIFICATE ISSUED�" 33. Final Electric /�eh Notes:- •¢ we, ,�/_ Ail 3 t£L, • z' K�t�3l7 LLD / -�� 34. Final Heating & Air Conditioning s'-" W� �u1T Setd--- •' Welk Atr-VC! 35. Final Gas Pipe-Test Vane" criOaf iv. 74o(ear 36. Hood or Canopy 37. Final Factory Fireplace HOLD FOR SPECLALBEQDIREu 2 pS 38. Final Plumbing (z-'-87 LEO 39. Water Service-Final it IbI l ik i!c? A �� ' � 1� 40. Gas Service-Final V r 41. Solar Domestic-Final 42. Backflow Preventer • 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations ` - - 47. FINAL STRUCTURE & BUILDING r9/j�/ti � • 48. Special Requirements Completed I/,u 18o? Z' / - • 49. Electric Release to Edison !/ 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY • No. Dale - r • 4111011e‘ CITY OF COSTA MESA , 4 BUILDING DIVISION `grOk" ^�'.. DEVELOPMENT SERVICES DEPARTMENT PERMIT PE IT NUMBER %%owns" 698-01640 (714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 1856 IOWA ST Status: ISSUED Suite: Applied: 09/14/1998 Vicinity: Issued: 09/14/1998 Parcel Nunrhber: 13904336 Zoning: Applicant: VOCKE, JAMES G Address: VOCKE, SUSAN COSTA MESA,CA Phone: 714-557-6746 C.M.,CA Zip: 92626 Owner VOCKE, JAMES G Address VOCKE,,SUSAN K - COSTA MESA,CA Phone: • - 1856 IOWA ST Zip: 92626 Contractor: • Address: Phone: , • Zip: . License: , Arch/Eng: Address: • . Phone:• Zip: License: SCOPE OF PERMIT -TEAR ROOF ROCK ROOF INSTALL FELT&REROOF WITH COMP.SHINGLES. FEE SUMMARY • Plan Check: $0.00 - Calc Valuation: $3,500.00 Permit: $87.25 -// Claim Valuation: . $3,500.00 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $87.75 PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 • NOTES: y EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 WORKERS'COMPENSATION DECLARATL 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: Carder: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,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 Signature: Date: 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 DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am 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: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subj cts 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 imself 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 s d within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code:The contractors I'cense w does not apply to an owner of property who builds or improves thereon, end who contracts for such project with a contractor(s) liter •th-Contract License Laws.). ❑ am a -1,•�tl:r:= Business and Professions Code for this reason: _ c r7 i :,.� �• Date: 7 71 • •' i verifi'd by dri er's license. Yes 0 No I ver's License No.) Exp r-..— a/lroJ- Verification of 0 nershi• by(type of docu�t,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title B,California Administrative Code). ❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or.present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health end 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 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes LJ No (Section 65050.2 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 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Alr 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 0 No 6 (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 „F C•,P'CE ' • AUTH RIZATION OF ENTRY:I certify under penalty of perjury that I have reed this application end state that the information given is correct. I agree • com•, w h . ate law and city ordinances relating to building construction,and authorize representatives of the City of Costa Mes000p to/snter upon the above-described• ••ei o i tion p ses.I agree not to occupy or allow occupancy of any building authorized by this permit until final insp 1 , •e•=tore-Of CegafOwner(3) ( Date Y/', fly •nd/Or Authorized Applicant Date CODE•. nr•, .i DATE MINS CODE. lB PFrmON TYPE GATE RIMS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final /0 /' ./ 206 Final Plumbing 200 Final Re-Roof — 6,A41. 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 • 12018 . '. • COSTA MESA BUILDING-SAFETY DEPARTMENT lit'' '. P. O. BOX 517 COSTA MESA. CALIFORNIA ( In .1 For Applicant to FBI In Completely APPLICATION FOR PERMIT TYPE OR PRINT BUILDING BUILDING ADDRESS 1856 Iowa St. COSTA MESA. CALIFORNIA For Office Use Only I RECEIPT NO. I jzo.. OWNER New York_Avenue Properties, Inc. /•",7j MAIL RECEIMEq BY D REE,ZIVE9 DATE ISSUED ADDRESS 41.9 E. 17th St• {L/I/.� I Lo/0--6. ma 1'�1360 TEL. BUILDING CITY Costa Mesa NO.Ll 81159 ADDRESS ARCHITECT Carlson & TEL. COSTA MESA. CALIFORNIA OR ENGINEER T.Lpddl0b cok NO Fi ADDRESS Garden Grove Z ZONE TYPE GROUPfJy CONTRACTOR Dike & Cell egrnve, Inn. BYPROVED DATE ADDRESS /119 E. 17th St. ZONING Sing]. faffi. NO.OF CITY Costa Mesa ZONRE 2 BUI DINQM1 I PLANSI USE OF gar.att STA C.NO. 167293 NO. Li 8-1159 LEGAL DESCRIPTION Lot 30, Tr• 3648 SIZE 1 NO. OF SLOGS. OF LOT 61 I x 100' NOW ON Loin A.P.NO. none USE OF YARDS EVES EXISTING BLDG. APPROVED ALLOWED SETBACK LINE FROM (CENTER LINE ST.) CENTER OF STREET 501 REAR YARD 301 FRONT FT. IN. /' 5ISIDE YARD I LEFT 61 RIGHT 51 R.SIDE FT. IN. DESCRIPTION OF WORK L.SIDE /lJ FT. IN. NEW I X I ALTERATION I II ADDITION I REAR 30 FT. /IN. REPAIR I V MOVING I I DEMOLISH I APPROVED BY L. D. DATE 5-13-60 BUILDINGNO. OF SIZE 1560 s9.ft.ROOMS 7 STORIES 1 EXTERIOR WALL I ROOF COVERING COVERING O USE OF BUILDING AND WORK TO BE PERFORMED attache_d Faraqe. 20A I HEREBY ACKNOWLEDGE THAT I HAVE READ THIO APPIJCATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE STATEAND _THAT THE ABOVE IB CORRECT AND AGREE TO COM) PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY ORDINANCES AND STATE( LAWREGULATING suiLoisa coNsTRUCTI VALUATION SIGNATURE OF / ' PERMIT FEE $ 36. a PERM ITTEF —27-2 o_ , � $ 16,101• PLAN CHECK $ 18• 4Y 1 • • f AUTHORIZED AGENT E TOTAL FEE • 0