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Home My WebLink About3244 IDAHO LN - Building Permits, • i � �= � CITY OF COSTA MESA - 'RpMFs'q '��`-' BIIILDING DIVISION � i� � 77 FAIR DRIVE, COSTA MESA. CA 92626 •(714) 754-5273 • Fax (774) 754-4856 • wvnv.ci.costa-mesa.ca.us : °.�� FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E09-00204 PERMIT TYPE ELEC STATUS: ISSUED APN: 13906606 DATE ISSUED: 0810512009 ISSUED BY: RMD JOB ADDRESS: 3244 IDAHO LN CM Vicinity: THROUGH OUT HOU$E Suite/Unit: SCOPE OF WORK: ELECTRICAL PERMIT FOR A COMPLETE REWIRE OF SFD WITH 37 LIGHT FIXTS, 41 OUTLETS, 30 SWITCHES AND UPGRADE SERVICE PANEL TO 200 AMP. '� � - OWNER: HUTCHINS, C EUGENE TR PHONE: 714305-2333 APPLICANT: HUTCHINS, C EUGENE TR PHONE: 714305-2333 CONTRACTOR: OWNER-BUILDER Address: Unit: PHONE: City/State: 2ipCode: ELECTRICAL PERMIT FEES Electrical Plan Check Fee: $0.00 Electrical Permit Fee: $155.04 Reinspection Fee $0.00 TOTAL FEES $155.04 Address: 1808 KINGLET CT Unit: City/State/Zip: COSTA MESA, CA Address: 1808 KINGLET CT Unit: City/State/zZip: COSTA MESA, CA License No. 000000 CELL: NOTICE: The work authorized by this permit shall wmply with all applicable handicap access requiremenls under Califomia sWtutes 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. INSPECiIONS: In order for the work authonzed under this permit to be considered legal, such work must comply with aii appiicable 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. OC pEt. INSPECTIONTYPE DRTE INIIiIAL COOE/ INSPELiIONiYpE p�T INi111A�5 1616 Fixed System Final Fir� prevention 20fi Final Mechaniral 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electricai %( � 201 Final Block/Retaining Wall 212 Final Fire Preven�ion 202 Final Factory Fire Placg 220 Final Planning Approval 203 FinalSign 222 FinalSite 204 Final Demolitian 250 Final Building/Occupancy � ` � , i WORKERS' COMPENSATION DECLARATION: I hereby aKrm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of conseM to self-Insure for vrorkers' compensation, as provided for by section 3700 0( the Labor Code, !or the peAormance of the work !or which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by sectbn 3700 of the Labor Code, for the pertormance of the work for which this permit is issuetl. My workers' compensation Insurence carrier and policy number are: Carzier (Thu serlion neetl rpt oe mmpele0 ✓ tne permq is val�etl a( me huntlredOdlars (StGtl) aless ) Policy Number: �[}'yl certify that in the peAortnance o( lhe work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensalion lavrs of California, and agree that if I should become subject ro the vrorkers' compensation provisions of Section 3700 0! the Labor Code_I shall forth '�h comply with these provision . % .f B� � 0 �% x �. --, - , �pP��nfs Si ure 1-B91e WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE IS UNLAWFUL AND SHALL SU&IECT 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, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensetl untler provisions of Chapter 9(commencing with Section 7000) o( Division 3 0( the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Conlraclors SignaWre �ate CONSTRUCTION LENDING AGENCY: ❑ I hereby aKrtn ihat there is a consiructbn lending agency fw lhe perfortnance o( the aork fa which this permit is issued (Sec. 3097, Gvil Code). Lender's Name: Lender's Address: Signature Date OWNER-BUILDER DECLARATIONS: I hereby aKrm that untler penalty o( perjury lhat I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Cotle: Any city or county which requires a permit to con5huct, alter, improve, demolish, or repair any stmcWre, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant Io Ihe 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 Ihe allegetl enemplion. Any violation of Sec[ion 7031.5 by any applicant for a permit subjects the applicant [o a civil penalry of not more than five hundred dollars ($500).�: �I, as owner o( the property, or my employees with wages as [heir sole o pensation, WILL DO THE WORK, and ihe strucWre is not intended or oftered (or sale (Sec. 7044, Business and Pro(essions Cotle: The Contraclors License Law does not apply to an owner ot property who builds or improves t�ereon, antl who does such work himself or herself or lhrough his or her own employees, provided that such impmvements are not intended or offeretl for sale. If, however, the building or improvemenl is sold within one year of completion, the owner-builder will have the burden o/ proving ihat he or she did nol build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRAC70RS to construct the project (Sec. 7644, Business and Professbns Code: The contractors License Law dces not apply ro an owner of pmperty �Mo builds or improves thereon, and wfio wntracts tor such project wi�h a contraciw(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: � � � �g T-L�awre'!p.+,�+ � �D e� ]05)-a6�]I01� � . Owner ID verifetl by driver's license. ❑ Yes .❑ No Driv�fs'L'ice_nse;No. � Ex. Ptresi � Venfication of Ownership by (type of document, i.e. - property �ax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify �hat no excavation fve (5) or more feet in depth into which a person is required to descend, will be made in connectbn with work authorizetl by Ihis pertnit, and that no builtling 5trucWre, scaffdding, falsev.ork, a demolition or dismantling ihereof, will be more than thirty-six (36) feet high. (Chap. 32, Grp 2. Ari 2, Sec. 341, Tdle 8, Calilomia Adminis[rative Cotle). ❑ As owner-builder, I will not employ anyone ro do work which vrould require a permit from the Division o! Industrial Safery, as noted above, unless such person has a permit to do such work from the division. Appliram's SignaNre Division of Industrial Safety Permit Number: _ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will lhe applicant or present or future builtling occupant need to fle and certify a Business Plan for emergency response to release or threatened release of a hazardous malerial? ❑ Yes ❑ No (Seclion 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Cosia Mesa Fire Depanment by every business which has at any one time dunng a reported year a quantity o( hazardous materials equal [o or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at slandard temperature antl pressure). 2. Does or will the applicant or present or future building occupant need to file a regisUation form (or acutely hazartlous ma�erials? ❑ Yes ❑ No (Section 25533 of the Califomia Health antl Safety Code, with some exceptions, requires registration vnth the Costa Mesa Fire Department by each business which at any one time has on hand a quantity ol acutely hazartlous matenals equal to or greater than a weight of 500 pountls, or a volume of 55 gallons, or 200 cubic feet of compressed gas al standartl temperaWre antl pressure). 3. Does or will the applicant or present or future building occupanl need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials�? ❑ Ves � No (Section 25534 0( Ihe Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Departmenl o( an RMPP by businesses which are requiretl to register acutely hazardous materials with the Fire Department. 4. It an RMPP is presently required, has Section 25534 of the California Health and Safely Code been fully complietl with? ❑ Yes ❑ No 5. Does or wiu the applicant or present or future building occupant require lor Ihe vrork which is Ihe subject of this appliwtion a pertnit for such construction or motlification Gom the South Coast Air �uality Management District or (mm any other air polWtion control disMct or agency? ❑ Yes ❑ No (SecCqn 658502 of Ne Califomia Govemment Code requires that the requestetl informa�ion be fumished on applications for nornresidential building pertnits). 6. Will any part o! ihe facility to be consiructed under this permit be vnihin 7000 feet from Ihe outer bountlaries of a school? ❑ Yes ❑ No (If "yes", the faciliry must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7. If a permit fmm the South Coast Air Quality Management District or other air pollution cOntml disMcl or agency is required for Ihe work which is the subject of this application, have all oi the disdosures prescribed by Califomia Health and Safety Cotle Section 42303 been made? ❑ Yes ❑ No 8. Qf yes", attach certificate o! compliance from the appmpriate air pollWion contml oKcer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury ihe information given above is correct I agree to comply with all state laws antl ciry ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certiry under penalty of perjury that I have read this application and sWte that the information given is correcL 1 agree to wmply with all state laws and city ordinances relating to building conslmction, and authorize representalives of the Ciry o( Costa Mesa to enter upon the above-Uescribed property (or inspection purposes. I agre not to occupy or allow occupanc of any building authorized b ihis permit til f 'nspection. � �J 0 . 5�^�e:c i:o.��e, s, o�r -i �—.. AnE/OrAulhOnzeE Ap0licxnl I � � � ;. � �`�—� �,,ity of Costa �I�lesa BuiCcfin� 1�ivisioii �'�'�� '�-- -• 77 Fair Drive, Costa Mesa, CA 92626 ��S-�CA lYA�sC,� 714-754-5273 / Fax 714-754-4856 C31lVfVER �UlLD�R V��I�I��`��Q� Permit#�� " V�� Disclosures & Forms for Owner- Builders Applying for Construction Permits IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been submitled in your name listing yourself as the builder of the property improvements specified at 3Ly-y Tpq o Lantc- Cos� �c'�q- Cq- 92G L� VVe are providing you with an Oamer-Builder Acknowledgment znd Informaticn Verifica ion 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 exewte this notice unless you, lhe property owner, obtain lhe prior approval of lhe permitfing authority. OWNER'S AGKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each sta ement below to signify you understand or ve�I(y�his in(ormation. ��. I unders[and a frequent practice of unlicensed persons is to have the property owner obtain an "O�vner- Builder" building permit lhat erroneously implies lhat lhe properly o�vner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject fo serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. h1y homeowner's insurnce may not provide coverage for those injuries. I am �vill{ully acting Cs an Ovmer-Buitder and am aware of the limits of my insurance coverage (or ir,juries to workers on my preperty. ��.. I understand building permits are not required to be signed by property o�a�ners uniess !hey ere responsible for lhe construction and are not hiring a licensed Contractor to assume this responsibility. �. I understand as an "Owner-Builder" I am the responsible party o( record on the permit. I understand ihat I may protect myself from potential financial risk by hiring a licensed Contractor and having th� permit filed in his or her name in5tead of my own. '�Y4� I unders[and Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and coniracts. �5. I understand iF I employ or otherv✓ise engage any persons, other than Califomia licens2d Contractors, and Ihe total v21ue of my conslruction is at Ieast five hundred dollars (5500), including labor and materials, I may be considered an "employer" under state and federal law. iV">`6?�I understand if I am considered an "employer" under state and federal law, I must register with the slzte and tederal govemment, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also undersland my failure to abide by th�sz laws �may subject me to serious financial risk. ��7:-I understand under California Centr2ctors' State License La�v, an Owner-Builder who 6uilds sing!e-family residential structures cannet legaily build them with the intent to otfer them for sale, unless all v:ork is performed by licensed subconlractors and the number of structures does not exceed four within any calendar year, cr all of the work is performed under contract with a licensed general building Contractor. �-8 I,uraderstand as an Owner-Builder if I sell the property for which this permit is issued, I may be held licbl� fo��any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction de�ects in the workmanship or materials. 1 of 2 . ___._ �. f�9. I understand I may obtain more informalion regarding my obligations as an "employer" from lhe Internal Reven'ue Service, Ihe United Sta(es Small Business Administration, ihe California Deparlment of Benefit Paymenls, and the Califomia Division of Indusirial Accidents. I also understand I may contacl Ihe California Contractors' State license Board (CSLB) at 1-B00-321-CSLB (2752) or �vw�v.cslb.ca.gov for more informalion about licen5ed conlraclors. ��. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am lhe party I?gaily and financially re=pon=ible for proposed cons!ruc!ion zcti�:ity at the follotsing zddress: �Z`f� SDltHo L.�F-.vE C�Ssq- �%/t-=5�4 CA' �jiLZG �11. I agree that, as ihe party legally and financially responsible for Ihis proposed conslruclion activity, I�a�ill afiide-by all applicable laws and requirements lhat govern Owner-Builders as well as employers. ,�15: 1 zgree to notliy the issuer of ihis form i�nmedia,ely of any additions, deletions, or changes to any of ihe informalion I have provided on fhis form. Licensed contractors are regulated by laws designed to protect the public. If you contract wilh someone who does not have a license, the Contractors' Stale License Board may be unable lo assist you with any financial loss you may sustain as a result of a complaint. Your only remedy againsl unlicensed Contracfors may be in civil court. It is also important for you to understand that if an unlicensed ConUactor or employee of lhat individual or firm is injured while working on your property, you may be held ! :�i ner-Builder and •. ti'o � ,_. � �_ �_ �I.^�.b e for damages. I �OU Cb fl 2 NEiiiit aS . 'riSi � �liic Cv(liiaCwiS, y'uLJ Vviil uc (25�iuiiSl�Jie for verifying whelher or not those Contractors are properly licensed and Ihe status of their �vorkers' compensation insurance coverage. i) 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 o( the property owner's driver's litense, form notarizafion, or other verification accepfab/e to the agency is required to be presented when the permit is issued to verify (he property owner's signa(ure. ✓ / C Signzture'of"(Z�Qp�rly rnvner �/� • C. 7 ^Jo;e: T"e fO�iG'vviT� n[iiiiv�IZoii0f7 FGii77 IS iBCjUfiB(j i0 ba comp�aiad by tl�e propaiiy uwneroniy �vir�n desrgnating an agent of the property o�vner to appty (or a construction permit (or the O�vner-Euilder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding tt�e Nolice lo Property O�vner, lhe execution of which I understand is my personal responsibilily, I hereby authorize the following persun(s) to acl as my zgent(s) to apply for, sign, and file the documenis necessary (o oblain an Owner-Builder Permit for my project. Scope of Canstruction 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 cerii(y its accuracy. fJcte: a copy of;ha owner's driver's license, iorm nofarization, or other veri(cation acceptab/e fo the agency is required to be presented �vhen Ihe pem�it is issued to verify the propeRy n�vner's signature. 4 / 7 3i o Property Owner's Signature: /" �' ` Date: // 9 2 Of 2 4 1 ♦ f CITY OFCOSTA MESA �- � `05` fq BUILDING DIVISION i � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • wv+w.ci.costa-mesa.ca.us � �.4�� fi. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX09-00155 PERMIT TYPE B MISC STATUS: ISSUED APN: 13906606 DATE ISSUED: 07/29/2009 Zoning: , ISSUED BY: BJK JOB ADDRESS: 3244 IDAHO LN CM Viciniry: GARAGE SQ. FT: 0 Primary Occ: Valualion: $14,000.00 SuitelUnit: Const Type :?? SCOPE OF WORK; CHANGE A 429 SF F�AT ROOF OVER EXISTING GARAGE TO A 2:12 PITCHED ROOF TO MATCH EXISTING HOUSE ROOF PITCH. ALSO REROOF ATTAHCED HOUSE AND GARAGE W ITH A MINIMUM OF 2 LAYERS OF 15# FELT AND REROOF W ITH ASPHALT SHINGLES, APPROX 2,179 SF. REPAIR AND REPLACE SHEATHING AS NEEDED. OWNER: HUTCHINS, C EUGENE TR City/State: COSTq MESA, CA Phone: 714305-2333 APPLICANT: HUTCHINS, GENE City/State: COSTA MESA, CA Phone: 714305-2333 CONTRACTOR: Address: City/State: Zip Code: ARCHITECT: Phone ENGINEER: Phone OWNER-BUILDER CHRISTINA R SILVA 714-374-5008 FEE SUMMARY Building Plan Check: Building Permit: Eleclrical Permit: SMIP Residenlial SMIP Commercial Bldg Std Admin Fund TOTALFEES Address:: 1808 KINGLET CT Zip Code: 92626 Address: 1808 KINGLET CT Zip Code: 92626 Phone $154.2t $237.25 $0.00 $1.40 $0.00 $1.00 $393.86 License No. 000000 License No. License No. 37201 Cell: Unit Unit: Unit: N0710E: The work authorized by this permft shall wmply with all applicable hantliwp access requiremenls under Cali(omia 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 fnal approval will result in the expiration of this permit. CO�M INSPEC110NIYVE OATE INTITIRLS GOOEi INSPECTIONTYPE ORTE IN7171R� i616 Fized Syslem Final F{re Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing Z00 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fira Place 220 Final Planning Approval 203 Final Sign 222 Final Site � 204 Final Demolition 250 Final Building/OccuOancy � � WORKERS' COMPENSATION DECLARATION: I hereby affrtm under penaliy of perjury one of Ihe following declarations: ❑ I have antl will mainlain a certificate o( consent �o sel(-Insure /or vrorkers' compensation, as provitletl for by seclion 3700 of the Labor Code, for the peAormance of the work !or which this permi[ is issued. ❑ I have and will maintain Horkers' compensation insu2nce. as required by sectbn 3700 of Ihe Labor Code, for the perfortnance o( the work for which this pertnit is issued. My workers' compensation Insurance carrier and policy number are: Carrier. (Tnrs sMm neetl rrol �e cwnpeted d Ne peimn is valued at one nundretlWllan (SIDO) orless ) Palicy Num6er: ❑ I certify that in the peAormance o( the work for which Ihis permit is issue0, I shall not employ any person in any manner so as to become subject to Ihe workers' compensation laws of Califomia, and agree lhat if I should become subject to the workers' compensation provisions of Section 3700 ot the Lahor Code, I shall foAhwith comply vnth these provisions. AOOlicanfs SignaWre Dale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE IS UNIAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (8700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affrm that I am licensed under provisions of Chapter 9(commencing with Section 7000) of Division 3 0( the Business and Professions Cotle, and my license is in full force and eftect. Lic. # Class # Gonvacmr's SignaWre Daie CONSTRUCTION LENDING AGENCY: ❑ I hereby aKrm that there is a consWction lending agency fw the peAortnance of Ihe work fa wfiich this pertnit is issued (Sec. 3097, Gvil Code). Lentler's Name: Lender's Atltlress: OWNER-BUILDER DECLARATIONS: I hereby aHirm that under penalty of perjury lhal I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business antl Pro/essions Cotle: Any city or counry which requires a permit to consimct. alter, impmve, demolish, or repair any structure, prior to its issuance, also requires ihe applicant for such permil to file a signed statement that he or she is licensetl pursuant lo Ihe provisions of the Contractors license Law (Chapter 9(commencinq with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempl therefrom and ihe basis tor the alleged eaemption. Any violation of Section 7031.5 by any applicant for a permit su6jecls the applicant [o a civil penalry of not more than five �untlretl dollars �$500).): ❑ I, as owner o! the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and Ihe structure is not intentled or offered lor sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not appty to an owner of property who 6uilds or improves thereon, and who does such vrork himself or herself or through his or her ovm employees, provided that such improvements are nol intended or oHered for sale. If, however, Ihe 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.). G I, as owner of the propeAy, am EXCLUSIVELY CONTRACTING WITH �ENSED CONTRACTORS to constmct the project (Sec. 7044, Business and Professbns Code: The wnt2ctors License Law dces not apply to an ovmer of property wfio builds or improves Ihereoq antl who contracts for such projecl with a contracta�s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business antl Professions Code for this reason: �2909 ' Signamre"+._ �„_.Dale . 3051�a6�3/0]) i. Owner ID verifietl by driver s license. Yes ❑ No Driver's License'No. (� Expires:' � � Verification of Ovmership by (rype of document, i.e. - property tax 6ill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICA710N: ❑ I hereby certAy that no excavation frve (5) or more feet in depth inlo wfiich a person is required to descend, will be matle in connection vrith work autlrorized by this permit, and that no building structure, scaftdding, falsework, or tlemolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 32, Grp 2. Ari 2. Sec. 341, Tille 8, Califomia Adminislra�ive Code). ❑ As owner-builtler, I will not employ anyone to do work which vrould require a permit from Ihe Division o( Intlustrial Safety, as no�ed above, unless such person has a permit to do such work irom the tlivision. Appliranfs Sgnalure Da�e Division o( Intlustnal Safery Permi� Number HAZARDOUS MA7ERIALS AND EMISSIONS CER7IFICATION: 7. Will the applicant or present or luture buildinq occupaM neetl to file antl certify a Business Plan for emergency response to release or threatened release ot a hazaraous matenal7 ❑ Yes ❑ No (Section 25505 0( the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed wi[h the Costa Mesa Fire Department by every business which has at any one time during a reportetl 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 (eet of compressetl gas at standard temperature and pressure). 2. Does or will ihe applicant or present or future building occupant need to �le a registration (orm for acutety hazardous materials? ❑ Ves ❑ No (Section 25533 0( Ihe Califomia Health and Safety Code, wilh some exceptions. requires registration with the Costa Mesa Fire Department by each business which at any one time has on hantl a quanlity o( acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressetl gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant neetl to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials�? ❑ Yes ❑ No (Section 25534 0( the Cali(ornia Health antl Safety Code provitles that the Costa Mesa Fire Depahment may require �he preparalion, certifcation and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with t�e Fire Depariment. 4. It an RMPP is presently requirea, has Seciion 25534 of the California Health an0 Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applican� or presenl or future builtling occupant require for the work which is the subjecl o( this application a permit !or such construction or motlifcation irom the SouN Coast Air Quality Management District or from any other air polW[ion control district or agency? ❑ Yes ❑ No (Section 65850.2 of Ihe Cali(omia Govemment Code requires that the requested infortnation be tumishetl on applications ta nornresidential building pertnits). 6. Will any part of the facili[y to De constructed under this permit be within 1000 feet fmm Ihe outer bountlanes of a school? ❑ Ves � No Qf yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Healih and Safery Cotle). 7. If a permil from the South Coast Air Qualiiy Management Disirict or other air pollution control district or a9ency is required for the work which is Ihe subject of this applicalion, have all of the disclosures prescnbetl by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. Qf'yes", attach certificate of compliance (rom the appmpriate air pollution contml oKcer�. CERTIFlCATE OF COMPLIANCE: I certify that under penalty of perjury the information given ahove is correcL I agree to comply with all state laws and city ordinances reqarding Hazardous Materials and Emissions. CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify untler penalty of perjury that I have read Ihis application and state lhal the information given is correcL I agree to comply with all state laws and city ordinances relating to building conswction, and authorize representatives of the City of Costa Mesa to enrer upon the above-described propeny for inspection purposes. I agree not to occupy or allow occupancy of any building auth�b�is per ii until I� f%na1 inspection. ` /� � 2. �/� 7/ Z % O SignaWredLegalOwneqs) 'Daie . _ _> AnGlo! AUV1oOEetl ApObWnl , � � �. �i�Sta l�✓ie�a ��.,y of Costa �I�Iesa �uiC, ig l�ivisiora 77 Fair Drive, Costa Mesa, CA 92626 714-754-5273 / Fax 714-754-4856 t�VV(�ER �UlL��R V��IFI�D `��C�� O � Permit # � (l�"�/J II �� 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 li ting yourselF as lh builder of the property improvements specified at 3 Z��{=13.4FJo L.9.v� ,�sr� L�c��s �►, �A 42 G z.� VVe are providing you u•ith an Ov:ner-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, lhe propeRy owner, obtain the prior approval of ihe permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DfRECTIONS: Read and initial each sfa ement 6elo�v to signily you understand or verl�y this in(ormation. ��. I understand a(requent 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 ov��n labor and material personally. I, as an Owner-Builder, may be held liable and subject lo serious financial 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 irjuries lo v�orkers on my prcperty. 9_' 2. I understand building permits are not required to be signed by property o�a�ners unless they 2re responsible for the construction and are not hiring a licensed Contractor to assume this responsibilify. �3. I understand as an "Owner-Builder" I am lhe responsible party of record on the permiL I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having th2 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 Cali(ornia and to list their license numbers on permits and contracts. � 5. I understand if I employ or othenn�ise engage any persons, other than Califomia licensed Contractors, and the total value of my construction is at least five hundred dollars (S500), including labor and ma,erials, 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 m�ith 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 faiiure to abide by thesz laws may subject me to serious financial risk. � 7. I understand under Califernia Centrzctors' State Lic=nse Law, an Owner-Builder who builds sing!e-family residential structures cannet Iegally build them with the intent to ofier them for sale, unless all v:ork is perform=_d by licensed subconfraclors 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. �8. I understand as an Owner-Builder if I sell the property (or which this permit is issued, I may be held IiaGlz for any financial or personal injuries sustained by any subsequent owner(s) that result from any lalent construclion defects in the workmanship or materials. 1 of 2 �� " �9. I understand I may obtain more information regarding my obligations as an "employer" from lhe Intemal Revenue Service, Ihe United Stales Small Business Administralion, lhe California Deparlment of Benefit Payments, and the California Division of Industrial Accidents. I also w�dersland I may contacl lhe California Contractors' State License Board (CSIB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed conlraclors. �' 10. I am aware of and consent lo an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed cons!ruc!ion acti�:ity zt the Folloi:�ing address: � 11. 1 agree tha�, as lhe party legally and financially responsible for lhis proposed construction acfivity, I�vill abide by all applicable laws and requirements thal govem Owner-Builders as well as employers. _ 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes fo any of the informalion I have provided on lhis torm. Licensed contractors are regulated by laws designed to prolect the public. IF you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you wilh any financial loss you may suslain as a result of a complaint. Your only remedy against unlicensed Contraclors may be in civil courL It is also imporlanl for you to understand that if an unlicensed Contractof or employee of Ihal individual or firm is injured while working on your property, you may be held �I2b!e for damages. If you cb.Hlfl ��Ef^llt oS .7'N�2f-�111��.Ef and v.•i;�l i0 hiic Cu(liiaCiuiS, y'GU Vvli� ue fe5pon;ibic for verifying whelher or nol those Conlraclors are properly licensed and the status of their workers' compensation insurance coverage. � � Before a building permit can be issued, this (orm 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 acceptab/e to ffte agency is required to be presented when the permit is issued to verify the propeity owner's signature. Signature oF properly ov:ner �C -� /Ej'�_ D2?e: 7 Z3 0� Note: T';e tol;o�.,'rg AuL;crization �orm is required to be cvn�pietzd by iliB p�opc�iy uw��Br' unly �vh�n desrgnating an agent of the property owner to appty tor a construction permit lor the Owner-Euilder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, lhe execution of which I understand is my personal responsibilify, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to oblain an Owner-Builder Permil for my projec�. Scope of Gonstruction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent Tel No I declare under penatty of perjury ihat f am ihe property owner for the address listed above and I personally fiiied out the above informalion and cerli(y its accuracy. fJole: A copy oltha o�vner's d�ivcr's license, iorm notarization, or other verification acceptable to the agency is required fo be presented �vhen the permit is issued to veri(y the propertyowner's signature. Property Owner's Signalure: Dale: 2 of 2 �.. OTpM �� 0 > t J 4o�p I� . /, , `+ � CITY OF COSTA MESA � � � BlIILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: M09-00074 PERMIT TYPE APN: 13906606 JOB ADDRESS: vicinity: SQ. FT: 0 MECH 3244 IDAHO LN CM SCOPE OF WORK: ALTER DUC TSYSTEM OWNER: PHONE: APPLICANT: PHONE: Address: City/State: r,; �:1 HUTCHINS, C EUGENE TR HUTCHINS, C EUGENE TR OWNER-BUILDER Unit: PHONE: ZipCode: MECHANICAL PERMIT FEE SUMMARY MECH ITEM FEE: $37.20 FLAN CHECK FEE: $0.00 INVESTIGATION FEE: $0.00 REINSPECTION FEE: $0.00 TOTAL FEES: $37.20 STATUS: ISSUED DATE ISSUED: 08/2112009 ISSUED BY: CAC Suite/Unit: Address: 1808 KINGLET CT Unil: City/Stale/Zip: COSTA MESA, CA Address: 1808 KINGLET CT Unit: City/State/zZip: COSTA MESA, CA License No. 000000 CELL: M,��,-ouo7a �"'r,: .�',!�; j � t? 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 auihorized under this pertnit 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. OEt. INSPELiIONTYPE ORTE INTIiIRlS COOE/ INSPECIIONTYPE ORTE IN TIAlS 1816 Fized System Final Fire Prevention 206 Final Mechanical „� 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BIocWRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 . Final Site '��, � i��+-b 204 Final Demolition 250 Final Building/Occupancy .� • . WORKERS' COMPENSATION DECLARATION: I hereby affrm under penalty of perjury one of Ihe (ollowing tleclarations: ❑ I have antl will maintain a certifiwte of consent to self-Insure (or workers' compensation, as providetl tor by section 3700 0( the Labor Code, tor Ihe peKormance o! ihe work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, fw the peAortnance of the wnrk fw vfiich this pertnit is issuetl. My workers' compensation Insurance carrier antl policy number are: Carrier (This secl.on neetl no( be mmplefed d(be permR is valuetl al one huntl�etl dollars (5100) or less J Policy Number: ❑ I ceAify that in the pertormance of [he vrork (or which this permit is issue4 I shall not employ any person in any manner so as to become subject Io the workers' compensation laws of California, and agree ihat if I should become subjecl to the vrorkers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. AO�IiwnCs 9gnature Date 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affrtn that I am licensed under provisions of Chapter 9(commencing with Section 7000) of Division 3 ot the Business antl Professions Code. and my license is in full torce and eftect. Lic. # Class # Camractor's SignaWre Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirtn that there is a constructan lentling agency for the peAormance o( the work for wfiich this pertnit is issued. (Sec. 3097, Civil Cotle). Lender's Name: Lender's Address: SignaWre Date OW NER-BUILDER DECLARATIONS: I hereby aKrm ihat under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW (or Ihe follovring reason (Sec. 7031.5, Business antl Professions Cotle� Any city or county which requires a permil to construct, alter, impmve, demolish, or repair any sWcture, prior to its issuance, also requires the applicant for such permit to fle a signed statement that he or she is licensed pursuant to ihe provisions o( Ihe Contrac�ors License Law (Chapter 9(commencing with Section 7000) of Division 3 0! the Business and Protessions Code) or that he or she is exempt lherefrom and the basis lor the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant ro a civil penalry of not more than fve hundretl dollars (5500).): ❑ I, as owner of ihe property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the siructure is not intended or oRered for sale (Sec. 7044, Business and Pro(essions Code: The Coniractors License Law does not apply to an ownei 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 intendeC or ofterea 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 t build or improve for purpose of sale.). I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LIC SED CON7RAC70RS to construct the project (Sec. 7044, Business and Professbns Code: The contractors License Law does not apply ro an owner of ro ert wfio builds or im roves thereon and who contratts for such ro'ect with Owner ven i by tlriver's licens�es ❑ No�� Dr' G eNo. � e. - property t x bill or tleetl): OIVISION OF INDUSTRIAL SAFE7Y PERMIT CERTIFICATION: ❑ I hereby certi(y that no excavation frve (5) or more feel in tlepth into which a person is required to tlescend, will 6e made in connection with work authonzed by t�is pertnit, and that no building structure, scaf(olding, falsework, a demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administ2tive Code). ❑ As ownerbuilder, I will not employ anyone to do work which woultl require a permit from the Division o! Industrial Safety, as noted above, unless such person has a permit to do such work fmm the tlivision. APWiranfs SignaWre Da�e Division of Indusirial Safety Permit Number HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future builtling occupant need to file and certily a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Cali(ornia Health and Safety Code requires, with some exceptions, that a Business Plan be fled with the Costa Mesa Fire Department by every business which has al any one time during a reponetl year a quantiry o( 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 tempereture and pressure). 2. Does or will Ihe applicant or present or luWre builtling occupant need to file a registration lorm for acutety hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Heallh and Safety Code, wilh some exceplions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely �azardous materials equal to or greater than a weight of S00 pounds, or a volume o! 55 gallons, or 200 cubic feet of compressed gas at stan0artl tempereture 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 Califomia Health and Sa(ery Code provides that the Cosla Mesa Fire Departmenl may require the preparation, certifica[ion and filing with the Fire Department of an RMPP by businesses which are requiretl to register acutely hazardous materials with the Fire Depanment. 4. I( an RMPP is presently required. has Section 25534 of the Cali(omia Health and Safety Code been (ully complied with? ❑ Yes ❑ No 5. Does or win the applicant or presem or fuNre builtling occupant require for Ihe work which is the subject of Ihis appliwtion a permit for such construction or modification from the Soulh Coast Air Qualiry Managemem District or from any other air polWtion control tlistrict or agency? ❑ Yes ❑ No (Section 658502 of the Cali(omia Govemment Code requires that the requestetl information be fumished on applications for non-residential building permits). 6. Will any part of the lacility to be constructed under this permit 6e within 1000 feet (rom the outer bountlaries o( a school? � Yes ❑ No Qf "yes", the facility must meet the requirement o! Sections 25534 and 42303 o( the Califomia Health and Safety Cotle). 7. It a permit (rom the SoWh Coast Air �uality Management District or other air polWtion contml distnct or agency is required for the vrork which is the subject of this appliwtion, have all o( the tlisclosures prescribetl by Califomia Health and Safety Cotle Section 42303 been made? � Yes ❑ No 8. Qf'yes", attach certifcate of compliance from the appropnate air pollution control oKcer). CERTIFICATE OF COMPLIANCE: I certify that under penalry of perjury the in�ormation qiven above is correcl. I agree to comply with all state lav5 and city ortlinances regarding Hazardous Materials antl Emissions. 9gnaWre Date P P Y � ' P� CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a cont2ctp(s) license pursuant to the Cont2ctors License Laws.). certify under penalty of perjury that I have read this appliwtion and state that ❑ I am exempt untler sec. the information given is correcL I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives o! Business and Protessions Code for this reason: the City of Costa Mesa to enter upon the abovetlescribed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �� O/ gnacure of Leg 1 vm� (� ate ' Signalo /� O/ate . � O ` 0 �09.46(3/O)) V AnElorA rrzedAy01¢anl at �,;`_ -.-�. -� --�� Costa Mesa _.: City of Costa �Vlesa BuiCding 1�ivision 77 Fair Drive, Costa Mesa, CA 92626 714-754-5273/Fax 794-754-4856 . OWNER BUILDER VERIFICATION Permit # M ��1' — 000 % � Disclosures & 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 yours If as the builder of the property improvements specified at 3 Z��-i .�� LR��'� ,��' � v`S/f' . We are providing you with an Owner-Builder Acknowledgment and Information erifcation 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 (or any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeown�r's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder an�i am aware of the limits of my insurance coverage for injuries to workers on my property. I �� ft5 2. 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. YT 3. t 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 California 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 law� may 5ubject 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. 3148-30 CALBO Jan 1, 2009 OB Packet template 1 of 2 �G Z6 i' . \ � I understand 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. �9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal evenue 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. 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: V\ 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. �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 wilh 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 responsibfe for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the aqency is required to be presented when the permit is issued to verify ti se property owner's signature. Signature of property owner ✓� -� /n� Date: � 7�/ On/ �— . 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 of the owner's driver's license, lorm notarization, or other verification acceptable to fhe agency is required to be presented when the permif is issued to veri(y the property owner's signature. Property Owner's Signature: Date: 3148-30 CALBO Jan 1, 2009 06 packet template 2 Of 2 OWNER � g�S�C. E. JOB ADDRESS ��4 Idaho La GENERAL CONTRACTOR ntrA AP No.l -OEi(-0� LOT INSPECTIOMS SOIL c�s W�TER ROUGH PLUMBIHG PROG. $v/F. LINE � NOUSE CON. SPRINKLING SVSTEM MISCELLANEOUS FOUGN ME�TIHG �N� �IR CONDITIONING TEMPOF�RY SEqvICE OR POLE UNOERGROUNO � POWER � � ROUGM WIRING TRENCHES � FOAMS STEE� RE FLOOA SVSTEM BONO BERM L STEEL REIN�ORCE � SNE�TNING FRRME ANO FL�SMING � PLPSTER ME�TING, PLUMBIN ELECTRI( BIIILOING ^ I I V�� I'I BROh'N COAT iAL FIN�L VENT., REFRIG. �ND A. ;, FiN�L �N� WS TEST I FIN�L FIN�L DATE SUBCONTRACTON , 4��+'2� � COSTA MESA BUILDINGSAFETY DEPARTMENT � �_ P.O. BOX 1200 COSTA MESA. CALIFORNIA 92626 � �� . 4899 i�jB,�±/7B 9.50 APPLICATION FOR STRUC7'URAL PERMIT Far ppplicant to Fill in Completely — Use Ink Only qEGEIVED BV DATE RECEIVED D TE ISSUED AD4RESS 3 z`F L D,4Ffo ��FNE ��` OWNER C .�+ � A.P.NO �Oy —O � BUIL�ING �� ' / y0 � � / MAI� AODRESS y /Y AODFESS TEL. 7qqCT % LOT� BLOCK CITy NO. CONSTFUCfION W ADD A P LEN�ER '�/ /� BRqNCH �y OWNE G_.E u /�lJ ADppESS VA� U`E �j �� ARCHITECT TEL. S Va DG� — OR ENGINEER N FIRE �� ADbFESS ZONE TYPE GROUP� APPROVED CONTRACTOR �,� C Q BY DATE � — AObRESS y b�s C`A �N�� TEL. ` ZONE NO.OF USE OF NEW X � 2 CITV � LI� NO.Sz'.�-�7�1•�• P�� UILDING R�P�� L C, Na. 2G 3 59 °��No.16363 VMAIDN BUILDING ACCE SORV BUOILDDING SIZE NO.OF BLDGS. (FROM C/L STREET) OF LOT NOW ON �OT ONT FT. FT. USF OF EXIS{ING BLDG. FT. Separate permits are required for �. sio FT. FT. electric, pl�mbing and healing work. FE FT. FT. U5� OF BUIIDING AND WORK TO BE PERFORMED DISTA CE BET. BET, MAIN & MA�N BLOGS. ACCESS. BLDGS. ^ � � VAft. qW �A7'E (i(fti(,� C.U.P.yW APPROVED APPROVE � � / 7 � h@�eby ecknowlaqpa thet I hava reetl [his eppt7eation antl smte � n that tha ebove InformeUon is correct entl aeree io comply wlth m oll lewf ro9uletinp bullding eonsuuction, and I shall not employ ony person In vlolatlon of Na workman's eompensation laws af m' Me Stete of Celitornia. I hareby cartify Mat I am properly IlcenseE es a contracmr untler SQ. FT. N tho SW[a of Cellfornia Business antl Profauians COGa, Division 3, THE AMOUNT SHOWN UNDER VAIUATION IS FOR m Chapter 9, entl that wch licensaz ara in full foree anG affact, or 1 THE PURPO6E OF ESTABLISHING A PERMR FEE ONLV: am exempt fram t�e prov(sions of the State of Celifornia e�stness iO VALUATION PERMIT FEE y a antl P�ofessions Cotle, Divislan 3, Chapte� 9. i ui m q PLAN CHECK E Signemre of .�S�/ QQ �� u Permittoo � L��'� �..LL.w � g�j ` D �� TAX E � � 0 I �� U /��horlSed AOent T07AL Pq1D E �� LJO Lot 26 Tr 3722 . � 2��0 CE�ST/'�AESA BUILDING-SAFETY DEPARTMENT P. O. BOX 917 G08TA MEBA. GLIFORNIA For Applieanf io Fill In Complefely TYPE OR PRINT COSTA MESA CALIFORNIA A A 1 ARCHITECf' TEL. I��TNo. 6 i i 95 No: M � 6-3zz7 SIZE ��. .�� • ______ INO.OPBI.D NONE BUILDING FIRE ZONH LBpAL FEE RECEIVED a�-�. '3 _6° -�� INANCE DEPT. APP� 1�A��O��t �PER,MIT BUILDING For Office Use Only P6CHIPT NO. P6RMIT NO. �!Y CAlB qEC V D DI�T[ 188UCO � /1J %��i� �61 Y 9 : . �:" CASTA MESA. CALIFORNIA ZONING NO. OF UBH OP Ne PLANB 2 I BLI�LDING W/• att I6 FnOM 6O � REAR YARO �.Ei * ��R L1N6 8T.) � ��T FRONT � I LEFT S� ( RIGHT yO t R SIDE I�/ DESCRIPTION OF WORK - __ , r, 1 BUILDING .�KG/ d- NO. OF USE OF BUILDINC AND WORK TO BE,PERRORMED iiNGIF FDMIIY QGCIf1GlJfF and Attached Garage Plan 7-CR 1 HEPfiBY ACKNOWLBDOH THAT I XAV6 pHAp TH19 AIPLIWTION ANU BT�Te THAT TXE ABOV6 19 CORRlCT AND A6RE6 TO COM- PLY WITH ALL CITY OPDINAN�H AN� 8TAT8 6 RIOUL�TINO 9UIlO1N6 CON9TRUGTION. /l /1 " . 1 AUTHORIZED AGENT -io- TX! AMOUNT 9XOWN IINOBH VALLIATION le POP THC PURP098 OP H9TABLIBFIING A P6RMIT F86 ONLY. VALUATION ' �L� PERMIT FEE $' . �I �— S /�l �� . PLAN CHECK $ �iJ � ' ' "_" '__ .. � �-�