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Home My WebLink About113 GEORGETOWN LN - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 113 GEORGETOWN LN Suite No Vicinity: Parcel Nunmber: 41916224 Applicant: MYERS, DAVID Address: 622 GAYMENT ST ANAHEIM, CA Owner: FULSEBAKKE, JUDITH ANN TR Address - 2950 BROADWAY #25 Phone: 714-827-6387 Zip: 92804 Phone: SAN DIEGO, CA Zip: 92102-2280 Contractor: D AND S ELECTRIC INC Address: 622 GAYMENT ST Phone: 714-827-6387 ANAHEIM, CA Zip: - 92804 1 License: 798166 Status: ISSUED Applied: 02/28/2003 Issued: 02/28/2003 ISSUED BY: SCOPE OF PERMIT , ELECTRICAL TO INCLUDE: INSTALL 4 NEW OUTLETS AND 1 SWITCH. LOCATED IN DETACHED GARAGE. 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 2446-46(&001 r FEE SUMMARY Quantity--> ---- - - -- - - Quantity ISSUE FEE $23.50 - " Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway /100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 - Transformers up to 1 kva/kw $0.00 0 Pool / Spa $0.00 0- - .....:..........up to 10 kvalkw $0.00 0 Lighting Fixts $0.00 0 -� - .......... up to 50 kva/kw .'....:.. $0.00 0 Recept Outlets $4.40 4 -, ._ ........:.....up to 100 kva/kw $0.00 0 Switches $1.10 1 - ..................over. 100 kvalkw- $0.00 0 Non Res Appl $0.00 o' Low Voltage Equipment $o.0o 0 Res Appl . $0.00, 0" Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp ' . $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand -, $0.00" ,-" 0 Motors to 100hp $0.00 0.. Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $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 2446-46(&001 r DECLARATiONS WORKERS' COMPENSATION D ATION: 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. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, For the performance of the work far which this permit Is Issued. My workers' compensation Insurance carrier and policy number are: Cartier: f d N% Policy Number: (Th/issection need not be ce plated if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certity that in the perto Trance 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 it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall fonhwith Comply with these provi s.� Applicant Signature: a� _✓/� Date: c41-��'--Q 3 WARNING: FAILURE TO SECURE WORKERS' COMPEN ON 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 em titan ed and Uro Vons 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. Lia P Y Class k C—/.O Contractoes Signature: Date: 2-2.r-03 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: Lenders 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 ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. It, 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.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ 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: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. 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 ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....._................ ....... _............ _.............................. ................................. -............................... .................................................. ............................................................. __.... _............................... .............._....... ................_................................. - 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the 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). ..._........_..........._........................... _.............. _......... _......................................... ............................................................................................. ...................................................... .................................................... _............ ............ ............. I............ 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 en RMPP is present) required, has Section 25534 of the California Health and Safe Code been full complied with? y q Safety y p ❑ Yes ❑ No ........................_............_..........................__.......rese...............___......... ildi..........................................................................................................................................plic.............a........................................................................... difi................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject c this a plication apeermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? � Vas ] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .............................. ............................................. .................................................................. ................................................................. ........... .................................. -....................... ................................... .............. ...._................................................ 6 Will any part of the facility to be Constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................. ................................................. ................................. -....................... .................................... -......................................... ...............-.............. __.......... ............. ................. ............................... .............. I..................... 7 If a permit tram the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................._ ............ _.............. ._....... _................ _........................................ _..-._.......................................................................................... ........................................ ..................... ............. .............. .................... ................... .............. 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 OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to Comply with all state laws and city ordinances relating to building Construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. � Signa Of Legal Owner(s o�ZR D3 Date -- AncIlOr Aut t rued Applicant Date CODE 0 INSPECTION TYPE DATE Iti1IDBL$ CODE • INSPECTION TYPE p g IKMIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Root 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 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 113 GEORGETOWN LN Suite: Vicinity: Status: ISSUED Applied: 03/19/2004 Issued: 03/19/2004 Parcel Number: 41916224 Zoning: Applicant: FULSEBAKKE, JUDITH ANN TR ISSUED BY: Address: 2950 BROADWAY #25 , Phone: SAN DIEGO, CA Zip: 92102-2280 Owner: FULSEBAKKE, JUDITH ANN TR Address . 2950 BROADWAY #25 Phone: - SAN DIEGO, CA Zip: 92102-2280 ' Contractor: Address: - - - Phone: - Zip: License:. Arch - - Eng: - - Address: Address: - - Phone: Phone: Zip: License: License: SCOPE OF PERMIT INSTALL (21 1/2" X 38 1/2") SKYLIGHT IN EXISTING GARAGE -ROOF (ICBG#ER-6078) NO RAFTERS CUT & SUBJECT TO FIELD INSP. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $300.00 Permit: $23.50 - - - Claim Valuation: $300.00 SMIP Res: $0.50 'SMTP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $24.00 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 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 446-46(6/00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit Is Issued. My workers' compensation Insurance carder and policy number are: Cartier: - Policy Number: (This section need not be completed it 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 SUB.IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLAAE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3/06 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. M Class N 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: Lenders 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 o1 Section 7031.5 by any applicant for a permit s7s the applicant to a civil penalty of not more than five hundred dollars ($500).): �I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors Licens 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 Con tors License Laws.). ❑ I am exemp Business and Professions Code for this reason: Signature: Date: Owner ID v y drivers license. es ❑ No Drivers License No. Expires: T 2 S 0 m Vent an of ership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certity 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, faisework, 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: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........_._..........__......._........__........_............__.........._............................................___....._........................................... .................................................. ..................................... .... ........................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the 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 it 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 en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ..__......._........_......._................._............_......__......................................_............................................................................................................................................................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application am mit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control distinct or agency? U Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................................................................................................................................................................................................................................................................................ ......................._............... _......................... .............. ._.... 6 Will any part of the facility, to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ... _......... _......... _........ _.......... _........... _........ _............................... .................................................................................................................................................................. .................. -.......... ................... ............. ........................................... 7 If apermit 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 appIr. lon, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .....__......._.......__........._...ertif._........._......_......................__........—_................................................................................................................................................................................._.............................................................................. 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 '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 com laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-dew opar y for insp 'purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signaturkobf Legal Owners) ? I I (O , / Date And/Or Authorized Applicant •7 4{- Date CODE 1. INSPECTION TYPE gAff. IINTITLALSS CODE# INSPECTIDN TYPE PAF lNi 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing -. 200 Final Re-Roof 210 Final Electrical 201 Final 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 I � C (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 113 GEORGETOWN LN Status: ISSUED Suite No Applied: 02/22/2000 Vicinity: INTERIOR REMODEL Issued: 02/22/2000 Parcel Nunmber: 41916224 Applicant: MILSTEAD, PAT ISSUED BY: Address: Phone:714-265-2012 Zip: -- Owner: FULSEBAKKE, JUDITH Address 113 GEORGETOWN LN, - - . Phone: .COSTA MESA, CA Zip: 92626 / n Contractor: PAT MILSTEAD ,� V Address: 14300 CLINTON SPACE46 Phone:- 714-265-2012 GARDEN GROVE, CA ,Zip: 92843 License: x757898 SCOPE OF PERMIT INTERIOR REMODEL OF EXISTING TOWNHOME. 5 LIGHTS, 22 OUTLETS AND 15 SWITCHES. SUBJECT TO FIELD INSPECTION PER PETE TENACE. _ REF300-00237 . FEE SUMMARY Quantity - - - - ISSUE FEE $23.50 Temp service test $0.00 Res. a/c package $0.00 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool / Spa $0.00 0 Lighting Fixts $5.50 5 Recept Outlets $13:20 12 Switches $31.00,-19, x. Non Res Appl -$0.00 1 ' 0 Res Appl ;'$0.00-� �,'0 '• Service to 200a $0.00 . \�0 Service to 1000a $0.00 0 Service over 1000a $0.00. 0 ' Motors to 1 hp $0.00 - ;' 0 Motors to 10hp .- '$0.00 '- �0 Motors to 50hp $0.00 _ - 0 Motors to 100hp $0.00 - T. 0 Motors over 100hp $0.00 -0 Communication drops $0.00'. 0 Temp Dist System / Lighting Busway 1100 f1 Standing Section Misc Electrical Equipment Transformers up to 1 kva/kw _ ................up to 10 kva/kw ...........`....up to 50 kva/kw .................up to 100 kva/kw ..................over 100 kva/kw, Low Voltage Equipment ,Low Volt Wiring System / Ckt Misc. Conduit Misc. Conductor Circus ( gen or ride) Circus (mech ride or lights) Christmas Tree Stand - Fireworks Stand Other Electrical Fee Quantity $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 Investigation Fee $0.00 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 2446-46(600) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) $j. 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 agree hat if I flould become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with mese pis Is Applicant Signature: i - Data: 7 WARNING: FAILURE TO SECURE 1 ORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL NALTIES AND GVIL FlNES UP TO ONE HUNDRED THOUSAND DOLLARE(S1O0,0DO), 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 1 am licensehapter 9 (commencing with Section 7000) of Division 3 of the Business and Prgtgssions Cade, and my license is in full force and effect. Lic. a %.i i5 Class a Gam/ V Contractors 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). Lenders Name: Lenders 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 ($500).): /•i ❑ 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 of 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 f4ir of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property. am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors LicenseLaw does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the CoritraclOrs License Laws.). ❑ 1 am exelfipt under sec. r' �. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers'licensei ❑ Yes ❑ No Drivers License No. Expires: .VerifiLtlon of Ownership by (type of document, Le. - 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, talsework, 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: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .._.....................................................................................................................................p'a'......................................................o'n................r'a,..................................................................................._................N,................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Ves ❑ 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 o1 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 ;To or present or future building occupant need to prepare an RMPP (Risk Management end 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. .__._..._...__.........._._........_._...........__............._.............................._.....................alif..................................................................................ly............................................................................................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ....__ ............................ .............. ............... ................... ........................ ........................................................................................................................................................................................ .................................. .......................................... _......... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? M Yes U No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). e WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................... ................................. .......................................................................................................... ........... ..................................................................................................... ............................................................................................. I.............. 7 II a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures Prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ......._........._.........._ ........... _........................................................................................................................................................................................................................................................................................................................................... 6 (If yes', attach certificate of compliance from the appropriate air pollution control officar). 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 property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Walure O gal O er(s) Date i�And/Or Authorized Applicant Date CODE t. INSPECTION TYPE 2AR INTMALg CODE INSPECTION TYPE g&TF. gig 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final 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 r<(�5� MFSq CITY OF COSTA MESA ' BUILDING DIVISION PERMIT NUMBER DEVELOPMENT SERVICES DEPARTMENT oarQ PERMIT E00-00141 (714) 754-5273 Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 113 GEORGETOWN LN Status: ISSUED Suite No Applied: 02/22/2000 Vicinity: INTERIOR REMODEL Issued: 02/22/2000 Parcel Nunmber: 41916224 Applicant: RONY JORDAN ISSUED BY: Address: 17611 WEBSTER ST Phone: (949)552-6289 IRVINE, CA Zip: 92614 Owner: FULSEBAKKE, JUDITH Address 113 GEORGETOWN LN COSTA MESA, CA Phone: Zip: 92626 Contractor: BUILT ON THE ROCK CONSTRUCTION Address: 17611 WEBSTER ST IRVINE, CA - Phone: (949)552-6289 Zip: 92614 License: 528944 SCOPE OF PERMIT INTERIOR REMODEL OF EXISTING TOWNHOME. 5 LIGHTS, 12 OUTLETS AND 10 SWITCHES. SUBJECT TO FIELD INSPECTION PER PETE TENACE. ' REF:B00-00237 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 FEE SUMMARY, Quantity Quantity ISSUE FEE $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway /100 it $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units)-' $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/ Spa $0.00 0 ................ up to 10 kva/kw $0.00 0 Lighting Fixts $5.50 5 .................up to 50 kva/kw $0.00 0 Recept Outlets $13.20 12 ................. up to 100 kva/kw $0.00 0 Switches $11.00 10 ..................over 100 kva/kw $0.00 0 Non Res Appl - $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to ihp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 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 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carder and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 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 WORKERSCOMPENSATION COVERAGE IS UNLAWFUL AND SMALL 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 lice d u er o 'si ns of Chapter 9 (Commencing with Section 7000) of Division 3 of the Business a ofessions Gode, and my license is in full force and effect. Lic. M Class k Contractor's Signature:Date: d CONSTRUCTION LENDING A CY: ❑ 1 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: Lenders 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 ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 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.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers 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 Cade). ❑ 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 ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant Or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ NO (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 6 Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescnbed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the ab ov -des ribed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. on Sign ure Off2gal Owner(s) ate XaW nd/Or Authorized Applicant Date INSPECTION TYPE PATE INTMALS CODE INSPECTIONTYPE p� INTITI LS 16c616 Fixed System Final Fire Prevention 206 Final Mechanical �„ p I T kJ' ' 1266 Pool Spa Final 208 Final Plumbing �hk pb 200 Final Re-Roof0 Fi lectncal 201 Final BIOck/Retaining Wall 12 Fire Pr ti 202 Final Factory Fire PI 220 Final Pla i Approval 203 Final Sign 222 Final Si e 204 Final Demolition 250 Final BuildinglOccupancy 244646 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT .lob Address: 113 GEORGETOWN LN Suite No Vicinity: Parcel Nunmber: 41916224 Status: ISSUED Applied: 11/13/2002 Issued: 11/13/2002 ISSUED BY: Applicant: SCOTT COLE Address: 2532 ORANGE AVENUE - UNIT B - Phone: 714-264-4190 COSTA MESA, CA Zip: 92627 Owner: FULSEBAKKE, JUDITH ANN TR " Address 2950 BROADWAY #25 - - - - Phone: - - SAN DIEGO, CA Zip: 92102-2280 Contractor: SCOTT COLE PLUMBING Address: 2532 ORANGE AVENUE- " UNIT B. - • Phone:- 714-264-4190 - COSTA.MESA, CA Zip: 92627 " - License: 758929 ' Arch / Eng: Address: - - - - Phone: Zip: License: SCOPE OF PERMIT PLUMBING TO INCLUDE: 1 SEWER PRIVATE LINE. REF.: B00-00237 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 $0.01) • 0 P -Trap $0.00 10 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,elc) ' $0.00 , . 0` ° Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0, - Septic Tank $o.00 o 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 $0.00 - - - Sewer Private Line $24.65 1 Water Closet (Toilet) $0.00 0 Drain, Roof $0.00. 0 - Shower $0.00 ,- 0 Water Heater / vent $0.00 0 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-parmit3--' FOR INSPECTIONS CALL: (714) 7646626 2666-46(6100) disk DECLARATIONS WORKERS COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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. ❑ 1 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 carver and policy number are: Carder: Policy Number: (This section need not be completed i/ the permit is valued at one hundred dollars ($100) or less.) 0 ��/' 1 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, d agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith covT mp) wily h the.. provisions �—(/� O pllcant Signature:} �'Lz1 Date' l� �3 /0 Z WARNING: FAILURE SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBIECr AN EMPLOYER TO CRIMINAL PENAL IES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,0001, 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 pereby;affimrthat-Pam licensed untler r vlsons of Chapter 9 (commencing with Section 7000) of Divisio 3 of the Business a d Professions Code, and my license Is in full +ii;-. I: 9¢.� g P force end�effact. Lic.,111 7 � 7 . Class a J aContidbtors SlgheWre:Date: o CONSTRUCTION LENDING AGENCY: ❑ 1 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). Lenders Name: Lenders 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 ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 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 contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby call 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, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) teat 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 ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to Or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..._..................................................................................................... ................................................................................ ................................................................... -...... .............................. ............................ ............................................. ............... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the 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). ._...._............_.__.........._ . Pro......... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention gram 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? ❑Ves ❑ No ........_........__......_...._..........._................._.........._._............................... ildi............................................................................................................................................................................................................................................difi............... 5 froea or will the applicant or present or future building t occupant require for the work which is the subject c this a plication a permit for such construction or modification from the South Coast Air Quality Management Distract or from any other air pollution control district or agency? � Ves j] No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ................................................................................................................................................................ ..................................................................si...................................................._......... ...._................ ......................Y.P.............................ty P ❑Ves ❑ No 6 Will an an of the tacili to be constructed under this permit be within 1000 feet from the outer boundaries of a school? (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 quired for the work w or agency is required Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ...._........___........._........._.........._..........__......_..._..............__.__—._.................................................._.....................................................................__............................................................................................. 6 (If yes-, attach certificate of compliance tram the appropnate 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 property for inspection purposes. I agree not to Occupy or allow occupancy of any building authorized by this permit until final inspection. Signet Of Legal Cw r(s) Date emote 7,- y 7 // 3 Z0"2 ht's. .,rrAuthodzed Appgcant ,Date CODE r. INSPECTIONTYPE gAi'E INTITAL$ CODE INSPECTION TYPE PATF 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 1 0 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining 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 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT .lob Address: 113 GEORGETOWN LN Suite No Vicinity: Parcel Nunmber: 41916224 Applicant: SCOTT COLE Address: 2532 ORANGE AVENUE UNIT B COSTA MESA, CA , Owner:. FULSEBAKKE, JUDITH ANN TR Address, 2950BROADWAY#25 - SAN DIEGO; CA - Contractor: SCOTT COLE PLUMBING Phone: 714-264-4190 Zip: 92627 Phone: Zip: 92102-2280 Status: ISSUED Applied: 11/13/2002 Issued: 11/13/2002 ISSUED BY: Address: ,2532 ORANGE AVENUE - UNIT B - Phone: ,714-264-4190 , - ''COSTA MESA, CA - Zip: -92627 ,- - License: 758929 . Arch /Eng: Address:.- ,• - _ -Phone: - ,- ' • - Zip:- ---- License: SCOPE OF PERMIT PLUMBING TO INCLUDE: 1 SEWER PRIVATE LINE. REF.: B00-00237 REVISE 1,1/18/02: ADD 1 WATER RE -PIPE. 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 �I '' '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 : ProcessPiping(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 , - -. Tank $0.00 0 - Wash Basin $0.00 0 Dishwasher $0.00. 0 -Septic 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 $24.65 1 Water Closet (Toilet) $0.00 0 Drain, Roof $0.00 0- -- Shower $0.00 0 Water Heater/ vent $0.00 0 Drinking Fountain $0.00 0 - -_- Sink, bar $0.00 0 Water Piping (Inst or Rep.) $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) 7545626 2446.46(6/00) AML DECLARATIONS WORKERS' COMPENSIATION DECLARATION: -" I hereby affirm, under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carder and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) 1 cedity 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 Califomia, an agree that it I sho d become subject to the workers' compensation provisions of Section 3700 0l the Labor Code, I shall forthwith comply with these provislons ' MAsp��pra: rrlicent'rignatu rWMANG-FAiCURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL! PENALTIES AND GVIL FINES UP TO ONE HUNDRED LT 1�OUSAND DOLLARE (St00p00), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37X OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I herebj y eMirm thatlam.licensed under rovisions of Chapter 9 (commencing with Section 7000) of Division 3��rrof the Business and Professions Code, and my license is in full m -toe and affect.CMr—:_ 7,} (Class a-1 C 6 ;, -Contradto_rsBignalure: Date:'--- / CONSTRUCTION LENDING AGENCY: ❑ 1 hereby allirn that there is a construction tending agency for the performance of the work for which this permit is issued, (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affimt 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 ($5DO).): ❑ I, as owner of the properly, 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 Cade: The Contractors License Law does not apply to an owner of properly 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 contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ YeS ❑ 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: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, TINe 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 hes e 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 ❑ NO (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........._................................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building Occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Cade, with some exceptions, requires registration with the Costa Mese 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 appplicant 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. ._........_.........._..........._........_....... ..__............._......_..._................,............................I..................................................................._............................................................................................................................................ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No ........................ ................................................... .........................................................................................................................................................................._................................................_......... .._............................................. _....... I ...... _..... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appennit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency' (J Yes O No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .............................. ....... .............. ....................................................... ,................................... ........................................................ ........................................................................ ......... via ................................................. I................. e Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................. ......._............................__........................................................................................................................................._..................................................................................................................................................... 7 If a irmit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ NO ............................................................................................................................................................................................................................................................................................................................................................................................ 8 (II 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 slate 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 property for inspection purposes. I agree not to Occupy or allow occupancy of any building authorized by this permit until final inspection. nture O at nor(s) / / 9 J 7 Date rrNCr'Authorized Applicant rOat-:,p CODE 1. INSPECTION TYPE �PE�PE RATE ILLS CODES INSPECTIONS-]jEPE g),¢, INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlockfRelaining Wail 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 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 113 GEORGETOWN LN Suite No Vicinity: Parcel Nunmber: 41916224 Applicant: FULSEBAKKE, JUDITH" Address: 113 GEORGETOWN LIN COSTA MESA, CA. - - FEE SUMMARY Owner: ' FOLSEBAKKE, JUDITH Address 113 GEORGETOWN LN COSTA MESA, CA Status: ISSUED Applied: 03/26/2002 Issued: 03/26/2002 ISSUED BY: Phone: 619-232-0079 Zip: 92628 r Phone: Zip: 92626 r Contractor: OWNER -BUILDER I t Address: Phone: Zip: License: 0 Arch / Eng Address: Phone: Zip: -., . License: - SCOPE OF PERMIT " PLUMBING PERMIT FOR INTERIOR REMODEL OF A SFD. 1 BATHTUB, 1 KITCHEN SINK, 2 WASH BASIN, 1 WATER CLOSET. REF: B00-00237 - 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 $9.80 1 Pressure Regulator - - $0.00 - 0 �Urinal 'i .%�� $0.00 0 Clarifier System . ' $0.00 '0 ' Process Piping (per 10 ft) $0.00 0 '� 'Vacuum Brki Bkflow(1-0) $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 $19.60 2 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) $9.80 1 Drain, Roof $0.00 0 Shower - '$0.00 ��, 0- - _ Water Heater/vent $0.00 0 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 Gas (1-4 outlets) $0.00 0 Sink, kitchen $9.80 1 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK - $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION ;. $0.00 0 Interceptors (Sand Auto ) $0.00 0 - TOTAL CALCULATED FEES:, $72.50 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 244646 (6100) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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 Cade, for the performance of the work for which this permit Is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed /t the permit is valued at one hundred dollars ($100) or less.) ❑ 1 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 ANDGVIL FINES UP TOONE 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 a 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 Cade). 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 sub'ecis the applicant to a civil penalty of not more than five hundred dollars ($500).): I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, 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.). C3I am exempt under sec. Business and Professions Code for this reason: Signature: Date: '312 -lie rQ 2 - Owner ID verified efs license. ❑ Yes ❑ No Drivers License No. Expires: i ZS Verification ofmer ip by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. 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 ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................. .................................................................................. ......................................................................................................... ..................................... __......................................... ..........._............._........................._. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the 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 ispresently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes [INo ..........._..........._........_......._........................ _........ _............................... ....._........................................................................................ ............................................................................... ..........................._.... ......................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agent? U Yes UNO (Section 65850.2 of the California Government Cade requires that the requested information be furnished on applications for non-residential building permits). .............. ............................................................................................................................................................................................................................_....................................._...... ..................... _............................................... ..._............. _......... e Will any pert of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If *yes, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ..............._.........................._..................................._..........._..............................................................-............................................................_.........................................__........................._......_....._............_.........._.........................._............ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..._..................._........._...........__................_.._........._....................................._........................................................................................................................................................................._.._...............-........................................_............. 8 (II 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 AUTHORIZA71ON OF ENTRY:,l c k ify 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 aand city ordinances rel in to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for iTf ction puroRles. I afro -seta c y allow occupancy of any building authorized by this permit mil final inspection. /VV1lll.. 7 12-16. r0 ?i Signature Of Legal Owner(s) I, Date And/Or Authorized Applicant Data CODE t. INSPECTION TYPE PIlIE ILLS CODE If INSPECTIONTYPE PATE Its 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing N1- 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Well 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 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 113 GEORGETOWN LN Suite No Vicinity: Parcel Nunmber: 41916224 Applicant: FULSEBAKKE, JUDITH Address: 113 GEORGETOWN LN- COSTA MESA, CA Phone: 714-904-6075 Zip: 92626 Owner:,/, FULSEBAKKE, JUDITH. Address=,113 GEORGETOWN LN - - Phone: - COSTA MESA, CA " Zip: 92626 Contractor: Address: OWNER -BUILDER ISSUE FEE' Temp service test ` .Res. a/c package New Res (1-2 units) New Res (3+units) Pool / Spa , Lighting Fixts Recept Outlets - Switches " Non Res Appl Res Appl A Service to 200a\,\,., Service to 1000a Service over 10006-\ Motors to the - Motors to 10hp Motors to 50hp Motors to 1 00h Motors over 100hp Communication drops Sub panel to 200a Pole Light Pkg Sign Circuits Temp Pwr Pole Intermed Pole -Phone: Zip: License: 0 Status: ISSUED Applied: 05/10/2002 Issued: 05/10/2002 ISSUED BY: ( COMMENTS / SPECIAL CONDITIONS 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 2+ (6100) 10 OUTLETS AND 5 SWITCHES. SCOPEOF..PERMIT REF B00-00237 - - -� FEE SUMMARY Quantity-= _ - ,' - . _ _ _ Quantity $23.50 - Temp Dist System /Lighting $0.00 0 $0.00 Busway /100 ft' $0.00 0 $0.00 Standing Section $0.00 0: $0.00 0 Misc Electrical Equipment $0.00 0 $0.00 0 Transformers up to 1 kva/kw $0.00 0 - $0.00 0 ......::........up to 10 kva/kw $0.00 %, 0 . 0 - ...............:.up to 50 kva/kw $0.00.0 . "$14.00 10 �. = ................ .up to 100 kva/kw $0.00 jib 0 ' $5.50 . 5 - ...............over 100 kva/kw __ $0.00 ,/ 0' $0.00, '� 0 � Low Voltage Equipment' $0.00" 0 ' $0.00 0 '-Low,Volt Wiring System / CkL =$0.00/. �, 0 $0.00 " -; A` 0 - - _ Misc. Conduit /$o 00 '� 0 �- $0.00 , .' 0:. z, _ Misc. Conductor '. - r $OAO 0 , -$0.00"'" 0 '_ - - Circus( gen or ride)-" $0.00% 0/ - ". $0.00," - 0 - Circus (meth ride or lights)' ' $0.00' '0 $0.00 0 Christmas Tree Stand $o.00, 0 $0.00 0- " Fireworks Stand- $0.00 - /0 $0.00 0 Other Electrical Fee $0.00 - $0.00 0 - $0.00 0- Investigation Fee - $0.00 $0.00 0 Plan Check Fee- $0.00 $0.00 0 Reinspection Fee $0.00 $0.00 0 $0.00 0 TOTAL CALCULATED FEES $40.00 $0.00 0 COMMENTS / SPECIAL CONDITIONS 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 2+ (6100) Ahh WORKERS' COMPENVTION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: - ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for -the performance of the work for which this permit is issued. ❑ 1 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: Polity Number: (This section need not be completed i/ 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 DOU_ARE ($10.000), 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 (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: ❑ 1 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 affirn that under penalty of perjury that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). 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 appy to n owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec.- Business and Professions Code for this reason re: m�e� c C Date: S r ID venfied b drivers license ❑ Yes ❑ No river's Licanse No. Expires -7 ZZ 2 Verification of Own Ip by (type of document, i.e. - property tax bill or deed . DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit. and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: 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 certity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................................................................................................................................................................................................................................................................................................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the 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 feat 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 [I No ............_.................._........_.........__..............—._........__........................................................................................................................................................................................................................................._.................................I............ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aped for Such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes L] No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). ....................................................................................._........................................................._..._......__.............................................................................................................. e Will any part of the facility to be constructed under this pemnit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................................._....................................__....................................................................................................................................___..............................__..................._.............._..........._..........................._................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes Cl 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 ertify 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 end city ordinances Tal g to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property ins pe 'o nrposa . to cc or allow of any building authorizedbymit until final inspection. 1) -2, Si re Of Legal Owners) �e And/Or Authorized Applicant Date CODE t. INSPECTIONTYPE INTRIALS CODE# INSPECTION TYPE JJ 1LYp 26M Ii�LS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 0o 08 Final Plumbing 200 Final Re-Roo�AC.DK 210 F' E trice 201 Final Bleck/R nl 212 a Pr nti n 202 Final Factory Fire Place 22 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy z I VERIFICATION A city or county, which is required to give notice pursuant to Section 19830, shall attach to such notice, and, as a condition precedent to issuing a building permit, require -the coinpletion and require the return of, an owner -builder verification. Attention Property Owner: An 'owner -builder' building permit has been applied for in your name and bearing your signature. Please complete and return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued until this verification is received. L I personally plan to provide the major labor and materials for construction of the proposed property improvement. ❑ Yes ❑ No 9.I have not) 6_ S signed an application for a building permit for ( ave the proposed work. 3. 1 have contracted with the following person (firm) to provide the proposed construction: Name Address City Phone ( ) Contractor's Lic. No. 1 plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work: Name ar k MOSCV& f Address City IYl V Phone ( ) Contractor's Lic. No. 5. 1 will provide some of the work but 1 have contracted (hired) the following persons to provide the work indicated: Name Address Phone Type of Work I N2<5 (REV. 9M) oeAzb&r Z9, 2 eoz 70 e:t�e � cwt M4tZ_ ,��c��p . 1Si✓.fir' oz-o63�s (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 113 GEORGETOWN LN Suite No Vicinity: Parcel Nunmber: , 41916224 Applicant: MILSTEAD, PAT Address: Owner: FULSEBAKKE, JUDITH Address -113 GEORGETOWN LN _ COSTA MESA, CA Phone: 714-265-2012 Zip: Phone: Zip: 92626 Contractor: PAT MILSTEAD ISSUED Address: 14300 CLINTON 05/10/2002 SPACE 46 Phone: 714-265-2012 " GARDEN GROVE, CA Zip: 92843 " Temp Dist System / Lighting License: 757898 Temp service test $0.00 SCOPE OF PERMIT 10 OUTLETS AND 5 SWITCHES. REF B00-00237 $0.00 - - Standing Section FEE SUMMARY Status: ISSUED Applied: 05/10/2002 Issued: 05/10/2002 ISSUED BY: �& � 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 2"6de (6/00) Quantity Quantity ISSUE FEE - $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 - Busway /100 ft - $0.00 0 Res. a/c package $0.00 - - Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) - $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool / Spa $0.00 0 ................up to 10.kva/kw $0.00 0 Lighting Fixts $0.00 0 ...............:.up to 50 kva/kw $0.00 0 Recept Outlets $11.00 10 ..................up to 100 kva/kw $0.00 0 Switches $5.50 5 ..................over 100 kva/kw $0.00 0 Non Res Appl - . $0,00 0 _ ' - Low Voltage Equipment $0.00 0 Res Appl - $0:00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 i� _ 0". Misc. Conduit - . _ $0.00 0 Service to 1000a' $0.00 0-" Misc. Conductor - $0.00 0 Service over 1000a° „'$0.00 '0 = . _ - Circus ( gen or ride) . $0.00 - 0 Motors to 1 hp - $0.00 -` 0,-- • .., Circus (mech ride or lights) $0.00 0 Motors to 10hp _ ' " $0.00 ,- "'01, Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 - Fireworks Stand - $0.00 " 0 Motors to 100hp $0.00 , 0 -. Other Electrical Fee $0.00 " Motors over 100hp $0.00 -' 0 Communication drops $0.00 - 0'; Investigation Fee $0.00 , Sub panel to 200a $0.00 -- 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 `. 0 ' 'Reinspection Fee $0.00 Sign Circuits $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 2"6de (6/00) DECLARATIONt WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carder and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) I cenity 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 at if hould come subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro ns / ,5 Applicant Signature: Date: % 1,59;7 /,9 WARNING: FAILURE TO SECURE WORK S' COMPENSATION COVERAGE IS UNLAWFUL AND SMALL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANDDOLLARE(SlO0.OD0),INAD ION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION WOO OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed oder r 's' n of Chapter 9 (comm cing with Section 7000) of Division 3 of theBusine and PjU¢saions Cade, and my license Is in full force and effect. Lic. If Class If Contractor's Signature: Date: CONSTRUCTION LENDING AGEN V: ❑ 1 hereby affirm that there is a construction lending agency for the periornance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders 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 ($500).): ❑ 1, 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. It, however, the building or improvement Is sold within one year,ot completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Caw does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tlile 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: 1 Will the applicant or present Or future building Occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ NO (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .._......_.._......._......_....._..........___.._...........................___............ildi.........................................__.__....._......-._.._..__........................................__............................_......................._....._.._..................._............_............._...... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .._.................... ...................................... _............................................................................................... ......................... ... ............. ........................................... ............... ... ........................ _......... ................................................................. _._.............. 3 Does or will the appplicant or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ N o (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 II an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Ves ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject ofthis application a eit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? lJ Yes �mNo (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _..........._..........._.......__........................._.........................................__......................................-h-in...........0f.....................................rb—o._.....afl-.................._._..............................................._.............._.................._............_............. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Ves ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............._.........._..........__...........__.............._............................................................................................ .............. ........................................................................................................._............................................................. 7 If a �ermit 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 appl cation, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ 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 slate 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 slate laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to Occupy or allow Occupancy of any building authorized by this permit until final inspection. (gnat gal Ovulerfal Data Antl/Or Authorize Applicant v Date CODE E. INSPECTION TYPE 2AM INTITAUS CODE r INSPECTION TYPE Lia¢, IfllTIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2D4 Final Demolition 250 Final Building/Occupancy WE (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 113 GEORGETOWN LN Suite No Vicinity: SFD Parcel Nunmber: 41916224 Applicant: MEYERS, DAVE Address: 622 GAYMENT ST Phone: 714-827-6387 ANAHEIM, CA ' Zip: 92804 Owner: FULSEBAKKE, JUDITH ANN TR Address 2950 BROADWAY #25 - SAN DIEGO, CA Contractor: D AND S ELECTRIC INC Address: 622 GAYMENT ST ANAHEIM, CA Phone: Zip: 92102-2280 Phone: 714-827-6387 Zip: 92804 License: 798166 Status: ISSUED Applied: 03/06/2003 Issued: 03/06/2003 ISSUED BY: n SCOPE OF PERMIT REPAIR AND COMPLETE UNFINISHED ELECTRICAL WORK:.2 GFI @ KITCHEN, 1/2 HOT @ BEDROOM #4,3 -WAY SWITCH @ DINING ROOM -AND 1 4 -WAY @ PATIO, VERIFY ONE 220V @ OVEN. 3 OUTLETS, 2 SWITCHES, 1 RES APPL REF: E03-00136 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) 7545626 2446.46(6/00) FEE SUMMARY Quantity _ " Quantity ISSUE FEE $23.50 Temp. Dist System / Lighting $0.00 0 . Temp service test $0.00 Busway /100 It $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 . " "0 Pool / Spa - $0.00 0 ................up to 10kva/kw, $0.00 ' 0 Lighting Fixts $0.00 0 . .................up to 50 kva/kw $0.00 0 Recept Outlets' $3.30 3 - .................up to 100 kva/kw $0.00 0 Switches - $2.20 2 ..................over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $4.75 1 - Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a '$0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $0.00 0 -Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 .0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 ' Communication drops $0.00 0 Investigation Fee $0.00 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) 7545626 2446.46(6/00) 1 r WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the perfomance of the work for which this permit is Issued. My workers' compensation Insurance Cartier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued atone hundred dollars ($100) or less.) 5_<1mrtify 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 Cell 'a, and agree Thal' should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro s. n / O Applicant Signature: _ Date: �� WARNING: FAILURE TO SECURE WORKERS' COMPENSATION ERAGE IS UNLAWFUL PND SHALL SUBJECT AN EMPLOYER TO CRIMI— NTTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S1OD.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 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. a Class Contractors 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). Lenders Name: Lenders 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.). ❑ 1, 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 contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers 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: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). ........._............__ ... ........... _................................... _........... _......................................... ................ ....__............................................................................................... ................. __..............._. ............................................ 2 Does or will the applicant or present or future building Occupant need to file a registration form for acutely hazardous matenals7 ❑Yes ❑ No ..........................._.. (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials aquato 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 Dces or will theapplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑WI (Section 25534 of the California ia 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. ...................................ii............................................................................._.............................................................................................................................................................. ..............._............ ...N�_ .............................................................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑No .._......_.........._........._.......... _.......... ................ __... ........ _.................................................. _..—_............................................................. ............._................................ ....................... ._................ _....................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apo mit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency: 88 Yes 8 No (Section 65850.2 of /he California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school?❑Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ......................................................................................................................................................................................................................................................................................................................................................................... 7 It 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 Califomia Health and Safety Code Section 42303 been made? ❑ Ves ❑ No ..................................... _.......... _............. ....... ......_......................................... _.. _... _.... _._...................................................................................................................................................................................................................................................... 8 (II "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 AUTHORIZAT10N OF ENTRY: I cenity under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �TY Si mat Legal Owners) Datfg And/Or AWonzed Applicant Date CODE t. INSPECTION TYPE IWMA CODE INSPECTIONTYPE gATE IIiTITALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plu g 200 Final Re -Roof 210 Fina ct Cal 201 Final Block/Retaining Wall to ng A ti n 202 Final Factory Fire Place 220 Final Planning A vel 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 4L0 9 CITY OF COSTA MESA BUILDING DIVISION > DEVELOPMENT SERVICES DEPARTMENTMIT NUMBER PERMIT ;E03-00156 ocap (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 113 GEORGETOWN LN Status: ISSUED Suite No Applied: 03/06/2003 Vicinity: SFD Issued: 03/06/2003 Parcel Nunmber: 41916224 $23.50 Applicant: MEYERS, DAVE ISSUED BY: Address: 622 GAYMENT ST - Busway /100 ft , Phone: 714-827-6387 Res. a/c package $0.00 ANAHEIM, CA Zip: 92804 Standing Section Owner:/ FULSEBAKKE, JUDITH ANN TR Address 2950 BROADWAY #25 SAN DIEGO, CA Contractor: D AND S ELECTRIC INC Address: 622 GAYMENT ST ANAHEIM, CA Phone: Zip: 92102-2280 -Phone: 714-827-6387 Zip: -92804 License: 798166 SCOPE OF PERMIT . REPAIR AND COMPLETE UNFINISHED ELECTRICAL WORK: 2 GFI'@ KITCHEN, 1/2 HOT @ BEDROOM #4,3 -WAY SWITCH @ DINING ROOM AND 1 4 -WAY @ PATIO, VERIFY ONE 220V @ OVEN. 3 OUTLETS, 2 SWITCHES, 1 RES APPL REF: E03-00136 - 3/12/03: SUPPLEMENTAL PERMIT TO ADD: 4 RECEPT OUTLETS, 1 SWITCH, 1 MISC ELEC EQUIP (COLD WATER BOND FOR JACUZZI. 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 244646(6M) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway /100 ft , $0.00 0 Res. a/c package $0.00 - Standing Section $0.00 0 New Res (1-2 units) $0.00 _ 0 Misc Electrical Equipment $18.20 1 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool / Spa - $0.00 0 ................up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 .................up to 50 kva/kw $0.00 0 Recept Outlets $7.70 7 .................up to 100 kva/kw $0.00 0 Switches $1.10 1 ..................over 100 kva/kw - $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $4.75 1 Low Volt Wiring System / Ckt $0.00 - 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) - $0.00 0 Motors to 1hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $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 244646(6M) W WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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. ❑ 1 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 s Ion need not be Completed if the permit is valued at one hundred dollars ($100) or less.) I codify that in the performance of the work for which this pennit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of alif ia, 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 pr isions. Applicant Signature: c Date: 3/12-14 WARNING: FAILURE TO SECURE WORKERS' COMP ATION ODVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO TH 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 (commencing with Section 7000) of Division 3 of the Business qOPrp(e d ssions Code, and my license Is in full force and effect. tic. N Class It C� Contractors Signature: Date: 3 L 6. CONSTRUCTION LENDING AGENCY: ❑ 1 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), Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that 1 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 pernit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such pernit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, 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.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers 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 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 ❑ 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? ❑Ves ❑ 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). .....__.........._............ __......... __........................................................................................._.._.._...._._......................................................................................................._........................................_......................................................I............ 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ Nla ((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 bapartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..........._....................._.........._.........._..................._................................................................................................................................................................................... -........_..... .............._....._..._............................_._.............._............... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No 5 Dome or will the applicant u present or future building occupant require for the work which Is the subject of this a plication ape No for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agent)? � Yes LI No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Willany part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Ves ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .......................... _.......... _.............................................................................................,...............................................................................................-. _... _._............................................................................................................................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................................... ................................................................ ................................. ............................................................. ................_..................................._..............................-...................... .............. ._............... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. naluLegal Owner(s) Date And/Or utho' d Applicant Z /ate CODE.. INSPECTION TYPE DQE INTRIALS CODE# INSPECTION TYPE DATE INTITAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 200 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final BlocktRetaining 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 Buiiding/Occupancy i (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 113 GEORGETOWN LN r - Suite: Vicinity: INTERIOR REMODEL Status: ISSUED Applied: 02/22/2000 Issued: 02/22/2000 Parcel Number: 41916224 Zoning: Applicant: RONY JORDAN -- _ ISSUED BY: Address: 17611 WEBSTER ST - i Phone. (949)55216289 - IRVINE CA,! ` - Zip: 92614 / / % r ". Owner: FULSEBAKKJUDITH Address 113 GEORGETOWN LNC r/ �, Phone. o0�COSTA MESA CA, �Zip: 92626 Contract BUILT,ON;THE'ROCK CONSTRUCTION /Address: 17611 WEBSTER ST ' Phone: ; (949)552-6289 IRVINE CA LS r _Zip �92814/ ..'License: '528944- ' tArch Eng: t Address:��-;Address_2, i - Phone: Phone Zip_,' License: `� �� License.- i SCOPE OF PERMIT REMODEL) EXISTING TOWNHOME, CHANGE WINDOWS, DOORS. -REMOVE DRYWALL AND REPLACE WITH NEW IOR"WORK INCLUDES THE REMOVAL OF EXIST. CEILING JOISTS INSTALLING FLOOR JOISTS FOR I 't� ORCEMENTS 1")' ICT TO FIELD INSPECTION PER PETE TENACE _ `�• / > -.; ' :� �� 1 X �� A, �, FEE SUMMARY % Plan Check: $254.31 Calc Valuation: �S25,000.00 1`\A r ,�, Permit \ ' $391.25 Claim Valuation: ��s$s; rnor:oo SMIP Reser '$2 50 SMIP�Com: $0.00 Other. ��>. Ins ecVtlon: --'$0.06\\-' t� Total- $648.067 G ° --'PLANNING=&ZONING SETBACKS \ )' MAIN STRUCTURE Front 0-0��.- Rear -0-0 jLen) 0-0 Right 0 ACCESSORY Front 0-0 Rearr-- 0-0.0 _ Left _0- 0 ., ;/ Right 0-0 PARKING Existing: 0 Required: 0 --Proposed: 0 NOTES: 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 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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 pertormame of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) Or less.) ❑ 1 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 it 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: Dale: 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. Uc. N Class x Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 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). Lenders 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 ($500).): ❑ 1, 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 Contr tors 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 emplo es, 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 -b it or 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 EXCLUSI LY NTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does a to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contract ). em t untler Business and Professions Coda for this reason: nature: — rilied by d' s license. as ❑ No' ers License N Expires: 7 Verification of Ship (type of document, i.e. - property tax bill or deed). V DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this Permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, 1 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 ❑ 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 thea licant or resent pp p or future building cocu ant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................. .............................................................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................................................................................................................................................................................................................................................................................... ........................................................................................... 4 If an RMP.. is presently required, has Section 25534 of the California Health end Safety Code been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject ofc this a plication aPPermit for such construction or modification from the South Coast Air Quality Management Distract or from any other air pollution control district or agency? � Yes LJ 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? ❑ Ves ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................. ................................................ ................................................................................................ ................ .................. ............ .... ... .............................................................. ..................... ............................................ I ........... ........... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............ ........................-.......... _.....................-_............_................................................................................................................................... ...........................-.......................................... ...................................................................................... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cartity under n f 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 ting to builtlin on t tion, and authorize representatives of the City of Caste Mesa to enter upon the above-described property for inspection agree not to occupy or at ow occu a c any building authorized by this permit un final inspection. 3I� ure Of Legal o r(s) DAB And/or Authorized plicant Date CODE I INSPECTIONTYPE IALINITTALS CODE I INSPECTION TYPE gAjF� INIMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final BlocWRetaining 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 7 D OWNER -BUILDER VERIFICATION A city or county, which is required to give notice pursuant to Section 19830; shall attach to such notice, and, as a condition precedent to issuing a building permit; require the completion and require the return of, an owner -builder verification. Attention Property Owner: An `owner -builder' building permit has been applied for in your name and bearing your signature. Please complete and return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued until this verification is received. L I personally plan to provide the major or and materials for construction of the proposed property improvement.. ❑ Yes-- No I (have/have not) /1 signed an application for a building permit for the proposed work. 30. 1 have contracted with the following person (firm) to provide the proposed construction: Name ` kwex_ 11 Address City Phone ( ) Contractor's Lic. No. 4. 1 plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work: Name Address City Phone ( ) Contractor's Lic. No. 5. I will provide some of the work but I have contracted (hired) the following persons to provide the work indicated: Name Address Phone Type of Work 100246 (REV. 9/98) /ej 4`�5t M6 9 CITY OF COSTA MESA BUILDING DIVISION - DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER (714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 113 GEORGETOWN LN Status: ISSUED Suite: Phone: Applied: 03/10/2000 Vicinity: SKYLIGHTS Issued: 03/10/2000 Parcel Number: 41916224 Zoning: Applicant: TERRY CAMPBELL ISSUED BY: Address: 2019 ORANGEVIEW LN - Phone: 714.637.0659 ORANGE, CA Zip: 92867 Owner: FULSEBAKKE, JUDITH Address 113 GEORGETOWN LN - Other: Phone: Inspection: COSTA MESA, CA Zip: 92626 Contractor: CAMPBELLAND ASSOCIATES GC Address: 2019 ORANGEVIEW LN Arch : Address: CA Phone: 714.637.0659 ORANGE Zip:, 92867 License: 761842 X Phone: Eng: Address: Phone: Zip: - License: License: SCOPE OF PERMIT - INSTALL TWO VELUX SKYLIGHTS PER NER 216.1 2X2 SKYLIGHT AND 1 2X4 SKYLIGHT, MONTICELLO COMMUNITY ASSOCIATION APPROVAL HAS BEEN RECEIVED FOR NEW SKYLIGHTS. SUBJECT TO FIELD INSPECTION PER PETE TENACE. FEE SUMMARY.' Plan Check: $15.28 Calc Valuation: $250.00 Permit: $23.50 Claim Valuation: $250.00 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $39.28 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 PARKING Existing: 0 PLANNING & ZONING Rear 0-0 Left 0-0 Right 0-0 Rear 0-0 Left 0-0 Right 0-0 Required: 0 Proposed: 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 WORKERS' COMPENSATION DECLARATION_— I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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 thP- 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 it 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 shou ecome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these proves' Applicant Signature: %y Date: 03 A 110-rp— WARNING: FAILURE TO SECURE WOR S' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (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. A. 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 apo Professions Code, and my license is in full force and effect. Dc. If Class N _ ///C Contractors Signature: Date: O 3 /ro /Of9 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm (hat there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders 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 ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of Completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: 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 contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ 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: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the 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? El Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aEEermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? UYes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer) CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of LeLe a� r(s) io And/or Authorized Applicant ' Date CODE 8. INSPECTION TYPE DATE INITTIALS CODE INSPECTION TYPE DATE INTMAL@ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final 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 BuildinyOaupancy 2446-46 v �� PROJECT ADDRESS: 1 1 3 GEORGETOWN LN UNIT: OWNER 'SNAME: SNYDER BEA H ADDRESS: 113 GEORGETOWN LN COSTA MESA,CA 92626 ARCHIENGINEER: REG.NO.: ADDRESS: UNIT: PERMITTEE: STOUT ROOFING INC (310)923-6775 ADDRESS: P O BOX 4309 DOWNEY CA 90241 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7030) of Division 3 of the Business and Professions Code, and my license is in full farce and effect. CITY LIC.: 059n 777 STATE LIC.: 402536 CLASS: C 39 EXP: 10/95 Date (� ab ) Signature:— _ WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation IBsrRapee2gc y,c¢Lfilied copy thereof (Section 3800. Lab. 65/19/95 L5 / 1 9 / 9 5 POLICY NO.: 77 66 L2 CC 7 7 EXP. DATE: U COMPANY: AIG ❑ Cerldied copy is hereby furnished. L'l Certified copy is filed with the city Building Division. Date: o � " Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred U100) or lessh I caddy 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, Date: Signature: NOTICE: It. atter making this declaration, you should d bema subject to the Workers' Com enation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for wh'on this permit is issued (Section 3097. Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of 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/she is licensed pursuant to the provisions of the ContractorsState License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). I, as owner of the property or my emvloyees with wages as their sole compensation, will do the work, and the El structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himselVherself 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 will have the burden of proving he/she did not build or improve for the purpose of sale). 1. as owner of the property. am exclusivelyy contracting with licensed contractors to construct the project(Setlion 7044, Business ❑ and Professions Cotle'. The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractor(s) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. & P. C. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will1will not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Air Quality Management District. Residential construction applications are exempt from these provisions. Date. Applicant I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above mentioned property for innsspeeccttioonn Ipurposes. Date:Jv/_p p.L_-1y--� Signature'�� Driver's license of Social Security a: 1641-46 White—Builtling: Green—Code Enforcement: Canary—Applicant, Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO; B 069518 PERMIT NO; B 069518 PLAN CHECK NO; N GOVT; N SUPP; N tlbNgtRuFtloN Typti V -N VERMIT TYpEE SIR PURPOSE; ALT JOB DESCRIPTION : T/O RESTH & REROOF W/gQFiiM& HOT MOP SQ FT: 2,508 CLAIM VALUE; 2,508,00 CALC-VALUE P- 2,508,00 GROUP OCC; R-1 / COMMENTS; REROOF SLOPE SIDE W/COMP FLAT SIDE BUR SMOKE DETE, REQUIRED Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR; FT IN FRNT: FT IN REAR; FT IN LEFT; FT IN RGHT; FT IN LEFT; FT IN RIGHT: FT IN PARKING REO• PROV; PARCEL; 41916224 ZNE; AEF NO: PLANNING N TES> FIRE SMIP/TOT GRADING PLAN—CHECK 54,00 > kkkkkkk kkk k kk k kk kk kitk kkk kkkk kkk k k k k kkk k k kkkkk k kkk kkk k kk kkkk kkkk kkk k k k,kk k kkk k k kk D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE; BUILDING APPROVED BY ; APPLICATION ISSUED BY: k kkkkkkkkkkkk k'k kkkkkkkkkkkkkk kkkkkkkkkkkkkkkkkkkkkkkkkkkkk LEGALIZATION;N BLDG PMT PLUMBING PERMIT 54,00 DATE; DATE; kkkkkkkkkkkkkkk;tkkkkkkkkkkkkkkkkkkkkkkk k k k� Iltkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk k'k kkkk kkk LL• E S U M M A R Y STRUCTURAL SEGMENT;Y ELECTRIC MECHANIC FIRE SMIP/RES GRADING ,50 SMIP/NON—RES PLAN ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 54,50 0,00 0,00 54,50 54,50 ,00 REVENUE DIVISION TOTALS--> COLLECTED; 54,50 OVER/SHORT; ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 54,00 .50 iF itk kit it k iF it iF Bt it Bt it kitk4k kit k it it it it it if itkkkitkkkif it k it it it it iF it itkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFR 2508 REROOF BY VALUE RESIDENTIAL NOZONE 1,00 2,508,00 END OF FEES 01 00170537-013170538 T O T DATE: 10/28/94 TIrE: 12:40 1] I CONSTRUCTION AND PLANNING Date Inspector POOL a .,PR Date Inspector APPROVALS Permit APPROVALS Permit =,k 1. Temporary Electrical Service or Pole - 52. Pool & Equipment Location j.r D 2. Soil Pipe-Undrgrnd. j 53. Steel Reinforcement -3"Electric8l CorBuitkJtility-Undrgrnd: 54. Forms " Eiettrical Coni3uit•L7ndrgrnd. 55, Electrical Bonding 5.,,*el Reinforcement _ 56. Rough Plumbing & Pressure Test ^' } �•t6,",ElectricalUF€R-Grnd. 57. APPROVAL TO COVER-GUNITE 7,;.F"ootings - "� 58. Electrical Conduit-Undrgrnd. ._ 87 -Foundation 59. Gas Pipe, ❑ Undrgrnd., Test r' 9 lWater Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, D Undrgrnd. -10. Structural Floor System V 61. APPROVAL TO DECK 11. Joperty Sewer Line & House Connection .r n• 62. Backwash & Receptor -Final 12. Sewer Cap-Final63. Heater &Vent a 13. Roof Drains .. 64. Plumbing System - Final 14. Rough Plumbing - 66. Electrical -Final 15. Rough Elec:ri:Cal-Conduit-. 66. Solar System -Final 16, Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring �ign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69, POOL/SPASYSTEflS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT ' Permit # r '• ` 20:�Ao6gh Factory Fire Place i rta,iAPPROVALS 21 'puct;, iAl St4uct UrleR - .; -.70. UnderggtmdHydro „ „ l; r .� 22 Dutts, Ventiaticg r >_ • _ t 71. ProducFRiPing C3Gas C1Oi1 r & ! t^. 23"Gas'PipFRough Test R -' " P -n 1 -1 - ,•_r •.t -72. Underground Flush, t ,1 _ .. 24:;RogfFraming 1,; - :!� . _ • ::73:jtUndergrnd.StoragB:�ankOGas -10 Oil r r - 25. RD0 Stleathing 7 ; r ,/��t� _4T / « "74.• Ayer head Hydro jr• ' 26.-rT-Bar Ceiling (Structural) &-Monocoat t/� ;t- 'i vt • = 75 "Dry Chemical J 27. frame and F1asRCn 76''1ry Stand"ipe %_�`r, •'i _28.'•Latfiing-& Siding; - ., -tti��: r ^. Y + a 77:' FIXED S4'STEhj FINAL- INAL-29. 1-29.Insulati� z ` i I IK 78=., -.FIRE PREY, FIN #'L n1 tr ,,•=30. Drywall. Nailing .nom - r I i^ - HEALTH:UEPT•. REQUIREMENT r-"31. Plaster brown Coat i P i -I; FINAL INSPECTION _. ,.79 •,J32. EleciR ; i-n�i Poiyer Meter -Final; ..� � Ir !. i 1 $O:vFOOD CERTIFICATE ISSUED •, 1 Electric - MI • r Notes: -"• '• .33.ina_I' I _i in4. CoQdnm itiog: ( �,: o• = ;; 35.:Finai-Gai Pipe•TEst' 'L' 1 R . � 36. Hood or•Cano +'37.:FinzilFa`etory Fireplace 38. Final, Plumbing •q; 'n; i e t i I IY • ,39. Water Service -Final' I �t l ` r X40. Gas Service -Final:=' ' Solar D6rnestic-Fmal_i •• r_ 1 �• R c:'_-� - t.' _--backflow Preventei F' " • 42. R •' i t ':~ rr, '' 43. Backflow Irrigation+ .44. Landscape 17.Rtgatioln Systemt'M , a• 'r45. Sound Atterivatiort ... ,.r o_ =46. Handicap Regulations -_ = r r :r 47.1FINAL STRUCTURE & BUILDING /_4_q� ��j' 7 W C9 t[ y -1 48.�'FINAL PLANNINGR i(( .. �- la r in _q •`' .. c49.Electric Release to Edison i 1• , ?] i ,.� i 50.•;Gas Release to Sou(hern California Gas Co 51. CERTIFICATE OF..00CUPANCY No. Date OWNER SAN VISE"A =ING COMPANY DATE 6-1-64 JOB ADDRESS 113 Georgetown Lane BUILDING PERMIT NO. 22295 GENERAL CONTRACTOR same VALUE $' 15,735.00 AP No LOT I7,2 TRACT 5160 FIRE ZONE DESCRIPTION OF WORK res watt ar INSPECTIONS Signature DATE - GROUP J&J TYPE SUBCONTRACTOR v ZONE PERMITS ISSUED P DATE NUMBER Ste'- - Water _ Rough om. Re g. Air Cond. F] Rough Heating/ Rough Plumbing Miscellaneous Prop. Swr. Line ❑ House Con., St. Swr. ❑ [C 4 1963 Sprinkling System Construction Pole Underground p Power ,p Rough Wiring Trenches L] Forms RK Steel Rtinf. - -/o-4703. 5 Floor System Bond Beam ❑ Steel Reinforce ❑ Sheathing O Frame and Flashin — Q � Lathing — In Out a G Plaster, brown coat Refri_g. ❑ Air Con. p Final Y / '°^^^='<• — 'F -ig, Final P- .Ring Fixtures Fi 1 Final Gas Test Electric Fixtures, Final Z- -fo Building, Final _ OCCUPANCY d i Yorm nus—sm—s-u:i—s-a Y sj(NT T) FOR SPECiA6 ^ r , 22• COSTA MESA BUILDING -SAFETY DEPARTMENT P. O. BOX 317 COSTA MESA, CALIFORNIA For Applicant to Fill In Completely TYPE OR. PRINT BUILDING [ARCHITECT DDRESS 113 Georgetown Lane' COSTA MESA, CALIFORNIA WNER San Vista Building Co. DDRESS 1166 E. 58th Street ITY Los Angeles 11,- Calif. No:AD 37187 R ENGIN ER Raymond Levanas NcOR 3701 3432 Via Oporto, NewportBeach ONTRACTOR San Vista Building Co. ADDRESS 1166 E. 58th Street ATE 192782 NEL. AD 37187 o. Shingle 20 X 7D AT HE ABOVE IS CORRECT AND AGREE TO COM. NO. OF SLOW ORDINANCES AND STATE LAWS R80ULATIND BU ILDINO C, NSTRU NOW oN Loi F None FIRE �� BLDG. -- APPROVED K LINE FROM F rEXISTING OF STREET I REAR YARD 0QDESCRIPTION AUTHOR I2 GfiNT .. , ARDI LEFT LEGAL DESCRIPTION Tract 5160 Lot I \� 3 S A. P. NO. OF WORK 30' TO SIDE a REAR P. L. I X II ALTFRGTVIN I II AODITIDN BUILDING �I O �� NO.OF SIZE eL ROOMS 7 E 8TOR1H8 CCO Shingle COVER NGWALStll COVERING AT HE ABOVE IS CORRECT AND AGREE TO COM. USE OF BUILDINe AlID WORK TO BE PERFORMED Resiaence r ^ FEE RECEIVED dAr i Q (��77FIINnnAFNC�En �DpEP�T.. APPLICATIOtJ' FCIR'�ERM11`SA BUILDING For Office Use Only nealPr NO. I HEREBY AC LEDGE THATI HAVE READ THIS APPLICATION AND STATE AT HE ABOVE IS CORRECT AND AGREE TO COM. PLY WITH ALL CIT ORDINANCES AND STATE LAWS R80ULATIND BU ILDINO C, NSTRU BUILDING TION. FIRE �� ZONE TYPE' GROUP - -- APPROVED SIGNATOR F PERMITTE UHH EW AUTHOR I2 GfiNT .. , FEE RECEIVED dAr i Q (��77FIINnnAFNC�En �DpEP�T.. APPLICATIOtJ' FCIR'�ERM11`SA BUILDING For Office Use Only nealPr NO. RBCHIV Y OAT CHV D ISSUED 'Cl JUIVTE ^r� U 1 1JO BUILDING ADDRESS FIRE �� ZONE TYPE' GROUP - -- APPROVED BY DATE ZONING NO. OPS UHH EW PLANE r BOK. 1 LEGAL DESCRIPTION Tract 5160 Lot I \� 3 S A. P. NO. NOTE: NO SAVE OVERHANG SHALL BE LEB THAN 30' TO SIDE a REAR P. L. EAVES ALLOWED (U.B.C. REQUIREMENT) YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (FROM REST) ' FRONT FT. FT. r�R. BI E FT. - L. SIDE IT. FT. REAR FT. FT. DISTANCE BET. BET. MAIN 3 MAIN BLDGS. ACCESS. BLDGS. VAR.# DATEleft C. U. APPROVED APP ftjoDATE THE AMOUNT SHOWN DER VALUATION IS FOR THE PURPOSE OF BETAS SHING A PERMIT FEE ONLY. VALUATION �/— PERMIT FEE $ i S/ 7,35— PLANCHECK S ��// •`7 6.s� TOTAL FEE