HomeMy WebLinkAbout2585 GREENBRIAR LN - Building PermitsI
(714) 754-5273 • f� (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR ORIVE, COSTA MESA, GA 92626
BUILDING PERMIT
Job Address: 2585 GREENBRIAR LN
Suite:
Vicinity: ROOF (GARAGE)
Parcel Number: 14137312
Applicant: LEAHY, PATRICIA
Address: 3335 NEVADA AV
COSTA MESA, CA
Owner: IMLER, MARY EVELYN TR
Address UNIT D403
COSTA MESA, CA
3400 AVENUE OF THE ARTS
Contractor: OW N ER-BU ILD ER
Address:
Zip:
Arch :
Address:
Phone:
Zoning:
Phone: 714-540-8119
Zip: 92626
Phone:
Zip: 9262G7625
Phone:
License: 0
Eng:
Address:
ISSUED BY:
Status: ISSUED
Applied: OB126/2002
Issued: 08/26/2002
Phone:
Zip: License: License:
SCOPE OF PERMIT
TEAR OFF EXITING ROOF. REPLACE SHEATHING AS NEEDED, INSTALL 50 YR, COMPOSITION SHINGLES, 30# FELT.
600 S.F. DETACHED GARAGE.
Plan Check: $0.00
Permit: $44.85
SMIP Res: $0.50
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $45.35
SETBACKS
MAINSTRUCTURE Front 0-0
ACCESSORY Front 0-0
PARKING Existina: 0
NOTES:
Rear 0- 0
Rear 0-0
Reouired: 0
FEE SUMMARY
PLANNING & ZONING
Left 0- 0
Left 0- 0
Proposed: 0
Calc Valuation:
Claim Valuation:
Right 0- 0
Right 0-0
s�,2o0.00
si,2oo.00
NOTICE: The work aulhorizetl by th(s permit shall comply with all applicable handicap access requfrements under Califomia statutes and related
regutations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This pertnit shall automatically expire antl become void if work is not commenced within 180 days, or if work Is suspended or ebandonetl
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such vrork must compy with all applicable cales, ena ell
requlred Inspectlona end final approvel must be obtained. Failure to obtain inspections and final approval will result In the expiration of this pertnit.
FOR INSPECTIONS CALL• (714) 7545628
2sea+e �am�
WORKE1iS' COMPENSATON OEGLARATION: _
I hereby ettirtn untler penal�y of perjury one ot t�e following deGaratlore:
❑ I heve entl wlll maintain e cenificate oi consent ta selt-Insure tor workers' compansation, es provitletl lor by section 3700 oi the Lebar Cade, lor the pertortnance of Itie
work for which t�is permit Is issued.
❑ I have and witl maintain workers' oompensation insurence, es requireA Cy sectlon 3700 ot the Lebor Cotle, lor �he perfortnance of Ihe work for whlch this permit is issued.
My workers' compensatlon Insurence carrler end pollcy numher are:
Carder. Palicy Number.
(Thls secfion need no! be comp/ete0 iI Ne permlf /s valued at one hundred tlollers ($100) or /ess.)
r�� I cenity thet in Ne pedortnence oi Ihe work la which ihis pertnit is issuetl, I shall not employ eny person In eny manner so es ro become sub�ect ro the workers'
compensetion laws of Celi la, entl egree that If I should bewme syp�ect to Ne workere' cnmpensetlon provisions ot Secllon 3700 ot the Lebor Code, I ahall forthwiN
compty with these pm ions. • L/
Applicem�Sipneture . L� {Dete:"?_� �c�G+ 'z! 1/
WARNINO.^FAILURE TO SEWHE WORKE0.S' G�OMPENSATION COVEMOE IS UMA FV AND SHN.L SUBIEGT Ml EMPLOYER TO CFIMINAL PENN.TIES AND qNL FlNES UP TO 0NE HUNDRED
T/IOUSANDDOIURE(5100,000),INADORIONTOTHECQSTOFOd.IPEN$ATION,O GESASPRWIDEDFORINSECTION3]O60FTHELABORCODE,IMEREST,ANDATTOFNEY5FEE5.
LICENSED CONTRACTORS DECLARATION:
I hereby efllrm lha� I am Ilcensed under provisions ot Chapter 9(commencinp wllh Section 7000) ol DlWslon 3 of I�e Buslness and Protessions Cade, entl my Ilcense Is in tull
lorce entl eflect. Llc. a Class a
ContrectoYs Slgneture: Date:
CONSTRUCTON LENDING AGENCY:
❑ I hereby eHirtn thet ihere is e consirucibn lending egency lor Ihe perlarmence oi the woAc for which Ihis permit Is issued. (Sec. 3097, CINI Code).
Lentler's Name: Lentlers AOdreu:
SlgnaNra: Oate:
OWNER-BUIIDER DECLARATIONS:
I hereby eHlrm t�et untler penalry ol peQury that I em E%EMP7 FROM THE CONTRACTORS LICENSE LAW Por the foilowing reason (Sec. 7031.5, Business entl Pmtesslons
Cotle: Any Gry or counry which reqWres a pertnit to consiruct, alter, imprwe, demdish, or repair any siructure, pdor ta its issuance, elso requires lhe applicant tor such pertnit
to lile e signed statement Nat he or she is Ilcensetl pursuant to Ne D«slons of Ihe Coniractors LJcense Lew (Chepier 9(wmmencinp wit� Sectlon 7000) ot Dlvision 3 01 Ne
Business end Prafessions Code) or Ihet �e or she is exempt thereirwn and ihe basis for tha ellegetl exemptlon. Any violatian of Sectlon 7031.5 by any epplicant for a permit
sub�ects the epplicant to e civil penalry ol not more Ihan Trve hundrad dollam (5500).):
❑ I, es owner ot the property, or my employees with wages as t�eir sde compensation, WILL DO TNE WORK, and ihe structure is not Intentletl or atteretl for sele (Sec.
7044, Business entl Proteuions Cotle: Tlie Contractors License Lew Coes not apply to en owner ot property who builds or impmves thereon, and who does suU work
himself or herself or through �is or her own employees, pravitleA Ihet such Improvements ara not InlenCetl or otfered for sele. It, however, ihe building or improvement is
sold within one year of wmpletion, Ne owner-builder will have the burtlen ot proving that he or she ditl not Duild or improve for purpose of sele.).
❑ I, es owner oi the property, em E%CLUSIVELY CONTRACTING WfTH LICENSED CONTRACTORS lo construct the projed (Sec. 7044, Business and Protessions
CoEe: The contrectors Llcense Lew does not eppty ro en owner of Dropetly who builds or Improves thereon, and who conirects tor such pro�ect with a contrectoqs)
license pursuant to the Contractors License Lews.).
1�_�:am ese r ec. Business and Prolessi ns Coda tor t�is reason:
� �.� ��.C... C'.;.�,..� S' -
S_�gnamre:= ���[ i � J � n Da e� Z �' (. — D`2./
Owner ID vanlied by drivers license. ,�Ves ❑ No �Drivafs Cleensa'No. �' �p�res: R-- 3-�.�
Verilicatlon oi Ownership by (rype of docGment, i.e. - property tax bill or
DIVISION OF INDUSTRIAL SAFETY PEHMR CERTIFICATION:
❑ I hereby certify ihat no excavetlon tive (5) or more feet in tlepl� into which a person Is requlred to tlescentl, wlll De made in canneciion with work euthonzed 6y Ihis
permll, and that no building sWcture, scaHWding, felsework, or demolition or tlismantling theraot, will be more ihan thirry-sia (36) leet high. (Chep. 32, Grp 2, An 2, Sec.
341, T(le B, Celifomie Atlmini5tretive Code).
❑ As owner-builder, I will nat employ enyone to tlo work which would reQulre e permil Irom ihe Dlvislon of Intlustrial Sefe�y, es nated ebave, unleu such persan has e
pertnil Io tlo such work Irom the tllvision.
Signeture: Date:
Divislon ol Industrial Sefety Permit Number.
CERTFICATE OF COMPLIANCE AND AUTHORIZA710N OF ENTRY: I certify under penalry of parjury that I have read ihis application end state thal the infortnation given is
correct I egree to wmply wilh ell stete laws anC city ortlinances releting to building conslruclion, enA euthotlze representatives ol the Ciy ol Costa Mesa to enter upon Ihe
ebove-descdbed pmperry tor inspection purposes. I egree nat to occuDY ar ellow occupancy of eny buil0ing euthorized by this pertnit unlil linel Inspection.
CODE �. INSPECTIONTYiE
1618 Fixatl Systam Finel Fire Provontlon
1266 Paol Spe Finel
200 Flnel Re-Roof ,
201 Flnel Block/Retaining Well
202 Flnel Factory Fire Place
203 Finel Sign '
204 Final Demolition
Q� �$
Dete
f� - B-G �O Z
t—oa�e �!
4QQ(j INSVECTIONTYPE
208 Finel Mechenical
20B Flnel PlumCing
210 Finel Elecidcal
212 Finel Fire Preventlon
220 Final Planning Approvel
222 Finel Site �
250 Finel BulldingiOccupency
QelE �$
DECLARATION��OF AUTHORITY
FOR AGEN7S OF PROPERTY OWNER
TO APPLY FOR PERMITS
Street Address:
1. I (we),
referenced real
�
and that I(we) hereby authorize:
BIdg.Pertnit# �-�����
This Permit #
AP Number:
declare that I am the Owner of Title of the above
Name: 0 f7i 2�c;.� L�:.9Nv TelephoneNumber. _7/y 5 NU -8!!S
Street Address: 3�.3 5 �d� /-N �'
City: l D_SY�+ /+/e?s!� state: �� Zip: `%��C
to obtain pertnits in my behalf, as owner/builder, for
at the above referenced property.
2. Should any person become an employee engaged in the improvement of the property, I(we) shall immediately provide Workers
Compensatlon Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa
Mesa, as required by State of Califomia laws.
3. As owner/buitder in fact, I understand and accept that my responsibilities do not transfer to any oiher person, company or
corporation.
4. I agree to indemnify and hold the City of Costa Mesa and its employees or o�cers harmless from any claim resulting in damage or
personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa.
5. I declare under the penalry of perjury that the foregoing is true and correct.
Executed this o7� dayOf 20 O 2, at C_O�b7.v /'LG�� , Califomia.
Print Name: ( � G //e� �/"�/'v��
� `.' �� �7
Signature: � Q
Date: r� —� � "� Q 2�
Note: This author¢ation does rwt grant authorization to perfortn the work as ovmer,
it solety p�ovides ior,Gmi[ed �wwer of attomey to secure this pertnR in any behalf.
ons-/s �.�.� iroa�
,
n
(714) 754-5273 • Fa�c (714) 754-4856 • www.cl.costa-mesa.ca.us � 77 FAIR DRIVE, COSTA MESA, GA 92626
BUILDING PERMIT
JobAddress: 2585 GREENBRIARLN
Suite:
Vicinity: ROOF (RESIDENCE ONLY)
Parcel Number: 14137312
Applicant LEAHY, PATRICIA
Address: 3335 NEVADA AV
COSTA MESA, CA
Owner: IMLER, MARY EVELYN TR
Address UNIT D403
COSTA MESA, CA
3400 AVENUE OF THE ARTS
Contractor: O W N E R-B U I LD E R
Address:
Zip:
Arch :
Address:
Zoning:
Phone: 714-540-8119
Zip: 92626
Phone:
Zip: 92626-7625
Phone:
License: 0
Eng:
Address:
ISSUED BY:
Status: ISSUED
Applied: 08/26/2002
Issued: 08/26/2002
I
,�✓
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
TEAR OFF EXISTING ROOF. REPLACE SHEATHING WHERE NEEDED, INSTALL 50 YR, COMPOSITION SHINGLES, 30#
FELT. 1970 S.F. FOR RESIDENCE ONLY.
Plan Check: $0.00
Permit: $97.25
SMIP Res: $0.50
SMIP Com: $0.00
Other: $0.00
inspection: $0.00
Total: $97.75
SETBACKS
MAIN STRUCTURE Front 0- 0
ACCESSORY Front 0. 0
PARKING Existinq: 0
NOTES:
Rear 0- 0
Rear 0- 0
Re uired: 0
FEE SUMMARY
PLANNING & ZONING
LeH 0- 0
Left 0- 0
ProDosed: 0
Calc Valuation:
Claim Valuation:
Right 0- 0
Right 0- 0
sa,000.00
sa,000.00
NOTICE: The work authorized by this permit sliall compty with all applicable handicap access requirements under Califomia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-27-92)
EXPIRATION: This permit shall automatically explre and become void if work is not commenced wlthin 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPEC710NS: In order for tha work authorized under this pertnit to be considered legal, such work must comply with all applicable codes, and all
required Inspectlons and final approval must be obtained. Failure to obtain inspections and final approval will resuft in the expiralion of this pertnit.
FOR INSPECTIONS CALL: (714) 7545626
244Bd8 (8�W)
WORKERS'EOMPtNSAnON DECLARATON:
I �ereby etfirtn under penalty of perjury one of the following tleclarations:
❑ I heve entl wlll melntain a certilicate of consent to self-Insure for workers' compenseHon, es provided for by sectlon 3700 ot the Labor Code, for ihe pertormanca of the
work for which ihis permit is Issued.
❑ I have entl will melntain workers' crompensetlon Insurance, as requiretl by sectlon 3700 0l the Lebor Code, for the perfortnence of the work for which this permlt Is Issuetl.
My workers' compensation Insurence carrier and policy numbar ere:
Cerrier. Pollcy Number:
(This section neetl nof be camplefed i! fhe permit /s velued ef one Aundred dWlero ($100) or less.)
�^�I cenity that in the pertormance ot the work br which this permit is issued, I shell no� employ eny person in any manner so as to bewme subject m the workers'
L�compensetlon laws of Calitomia, end egree thet II I should become ib�ect to the workers' compensation provisions ol Sectlon 3700 oi the Labor Code, I shell forthwith
comply with these p avisi ns. •
ApplicemSlgnature: �-� �Date:+�� " fi-L, — L� 9
WARNIN(%'FAINRETOSEWiiEWOHKERS'COMPENSATIONWVERAGEISUMAW SHP11SUflIECTANEMPIOVEHTOCHIAUWILPENALTIESPNDCMLFlNESUPTOONEHUNDiiED
TMOUSPND DOLLARE (3100,000), IN ADDRION TO TME WST OF COMPENSATION, DAAM AS PqOVIDED FOR IN SECTION 3�O60F THE LABOR CODE, IMEREST, PND ATfORNEV'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aflirm that I em licensed untler provislons of Chepter 9(commencing with Sectlon 7000) of Olvision 3 of the Buslness and Professions Cotle, antl my license is in full
force entl effect. Llc. N qass M �
Contrectors Signature: Da�e: '
CONSTRUCTON LENDING AGENCY:
❑ I hareby aMirtn that there is a consiruction lending egency far tha pertormence oi Ihe work for which this permil Is issuetl. (Sec. 3097, Civil Code).
Lentlers Name: Lenders Address:
Signature: �ate:
OWNER•BUILDER DECLARATIONS:
I hereby ettirm thet under penalty of perjury thet I em EXEMP7 FROM THE CONTFiACTORS LICENSE LAW tor the following reason (Sec. 7031.5, Business antl Professions
Cotlo: Any city or county which requires e permit to construct, elter, improve, demolish, or repair eny stmcture, prior to Its Issuence, elso requires ihe epplicant tor such pertnit
to ille a signetl stetement �hat he or she Is Ilcensed pureuent m ihe provislons of ihe Contractors License Law (Chapter 9(commencing with Sedion 7000) of Dlvlsion 3 of the
Business antl Professions Code) or that he or she Is ezempt thereirom and the besis for the alleged e:emption. Any vloletlon of Sectlon 7031.5 by any epplicent for a permlt
subjects ihe epplicsnt to a civil penalry oi not more ihan flve hundred dollars ($500).):
❑ I, as owner ol Ihe properry, or my employees wilh wages es t�eir sole wmpensatlon, WILL DO TT1E WOFiK, antl the structure Is not Intended ar ottere0lor sale (Sec.
7044, Business and Professions Code: The Con�rectoro License Law tloes not aOP�Y �o an owner ot property who builds or improves thereon, and who tloes such work
himself or hersetl or thmugh his or her own emplayees, provitletl ihat such improvemenis are not Intended or ottered lar sale. tl, however, the building or Improvement is
sold wilhin one year of completioq �he ownerbuilder will have the burden of proving that �e or she did not build or improve for purpose ot sale.).
❑ I, es owner at Ihe properry, am EXCLUSIVELY CON7RAC71NG WI7H LICENSED CONTRACTORS to consWCl �he pmject (Sec. 7044, Business and Prafessions
Cade: The contractors License Lew tloes nm appy lo an owner ol property who builds or ImOroves thereon, enU who wntracis lor such prolect wii� a contrector(s)
l,( licen5e DurSuent to ihB Conlrattor5 Liten58 Lews.).
�Ipl�l em exe��a6ttNder;ec.—'-� _ � 8usin¢ss �ntl Pmlessions Code br �his reason:
Owner ID verified by drivers license. Ves � No U
Vedlication ot Ownership by Qype of tlocu e, i.a. - propeny x bill or tleetl):
DIVISION OF INOUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby caNty Ihat no excavetion tive (5) or more feet in depih into which e person is required to descend, will be made In connection with work authorizetl Ey this
pertnil, antl that no building structure, scatfoltling, falsework, or demolition or tlismflntling thereof, will be more Ihen thirty-si: (36) leet hiph. (Chap. 32, Grp 2, Art 2, Sec.
341, Tnle 8, Calilamia Administrelive Code).
❑ As owner-huilder, I will not employ enyane to Co work which woultl require e pertnit trom Ihe Division oi Industnel Sefery, as noted ebove, unless such pereon hes e
permit to do such work from Ihe tlivlslon.
Sipnature: Date:
Division of Indusirial Safery Permit Number:
CER7IFICATE OF COMPLIANCE AND AUTMORIZATON OF ENTRY: I certity untler penal�y of perjury that I have read ihis epplication end state Ihat lhe information given is
correct. I aqree to comply with all stete lews entl ciry ordinences relating ro Guiltling wnstruction, end euthonze representetives of t�e Ciry ot Costa Mesa to enter upon the
above-described property for inspectian purposes. I egree not to occupy or ellow occupancy of eny building authorized by thls permit until final inspection.
cooe �.
1818
1288
200
201
202
203
204
Fixetl System Flnal Fire Preventlon
Pool Spe Finel
Finel RB-Rooi
Finel Blak/Retaining Well
Finel Fattory Fire Place
Final Sign
Final Demolition
PAg I[�L$
f 0 ^/a^DZ �
Date
R -.�-� - v z
� Date j
COOE� INSFECTIONTYPE QajE �{�5
206 Final Mechenical
208 Flnal Plumbing
210 Final Elecidcel �
212 Final Fire Prevantlon
220 Final Planning Approval
222 Final Site
250 Final Building/Occupflnq
DECLARATION OF AUTHORITY
FOR AGENTS OF PROPERTY OWNER
TO APPLY FOR PERMITS
Street Address; cY ��
BIdg.Permit# �i�-�-=✓—������
This Permit #
AP Number:
1. I(we), r� , declare that I am the Owner of Title of the above
referenced real pro rty, and that I(we) hereby authorize:
Name: �T(=�G�/J' LL�%y Telephone Number: 7/ �1 S�/O -b'l(�
StreetAddress; 3�35 �%�✓e
city: 1��5Y7�F l�%.sR state: Qf�' zip: �%1-G �G
to obtain permits in my behalf, as owner/builder, for
at the above referenced property.
2. Should any person become an employee engaged in the improvement of the propeRy, I(we) shall immediately provide Worker's
Compensation Insurance coverage and cause a ceAificate of that coverage to be filed with the Building Division of the City of Costa
Mesa, as required by State of California laws. '
3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other person, company or
corporation.
4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or
personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa.
5. 1 declare under the penalty of perjury that the foregoing is true and correct. /�
Executed this _�L day of � 20 b 2, at C.D-U �iv /�L �^ , California.
/C�J �/�
Print Name: r /�,�Q/(//��.L�'f�
� �� �;
Signature: '�� �
Date: �� � (� "' Q 2�
Note: This auttrorizaEon does not grant authorization to perform the work as owner,
it solety provides for limded power of attomey to secure this permit in any behalf.
0779-06 (�ev.11/00)
��ia) �sa-sz�a • Fax pia� �sa-aess
Job Address:
Suite No
Vicinity:
CITY OF COSTA MESA
BUILDING DIYIS/ON
DEVELOPMENT SERViCES DEPARTMENT
PERMIT
2585 GREENBRIAR LN
Parcel Nunmber: 74137312
Applicant: BEEKER, ANDREW
Address:
owner: IMLER, GORDON W
Address: P O BOX 3185
COSTA MESA,CA
Contractor: KLONDIKE AIC & HTG
Address: 13081ogan
SUITE H
Costa Mesa, CA
ArchlEng:
Address:
ISSUE FEE
Inst FAU <100 k BTU
Inst FAU >100 k BTU
Repair/Alt Cooling/Heat
Inst / Rep. Recess Wall Htr
Refrig Sys <700 k BTU
Refrig Sys >100 k BTU
Gas Piping
Factory Fireplace
Hood w/Mech Exhausl
VAV Box
Venl Fan / Single Duct
Appliance
Fire Dampers
Smoke Dampers
Inst or Relocate Appl Vent
Air Handiers < t0000cfm
AirHandlers> 10000cfm
Floor Fumace
Floor or Suspend Heater
MECHANICAL PERMIT
Phone:
Zip:
Phone:
Zip: 92628
Phone: 979-2070
Zip: 92626
License: 754456
Phone:
Zip:
License:
SCOPE OF PERMIT
REPLACE FURNANCE IN EXISTING RESIDENCE.
$22.00
$13.25
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
so.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
so.00
$0.00
Quantity
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
FEE SUMMARY
ERMIT NUMBER
M99-00004
77 FAIR DRIVE, COSTA MESA, CA 92626
Repair / Alt Absorbtion Unit
Repair / Alt Refrigeration Unit
Ventillation System
Evaporative Cooler
Com me rcial I ncinerator
Domestic Incinerator
Compressors / Absorption Svstems
Upto3hplt00kBTU
3To15hp/SOOkBTU �
15 To 30 hp / 1,000 k BTU
30 To 50 hp I 1,750 k BTU
Over 50 hp / Over 1,750 BTU
Boiiers
Up to 3 hp
3To15hp
15to30hp
30 l0 50 hp
Over 50 hp
Other Mechanical Fee
Investigation Fee
Plan Check Fee
Reinspedion Fee
TOTAL CALCULATED FEES
COMMENTS / SPECIAL CONDITIONS
Status: ISSUED ��'j
Applied: 01/O6I1999
Issued: 01/O6/1999
Quantity
$0.00 0
$0.00 0
$0.00 0
80.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
so.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00
so.00
$0.00
;35.25
EXPIRATION: This permil shall automatically expire and become void if work is no� commenced within 180 days, or if work is suspended or abandoned
for a period ot 180 days. .
INSPEC710NS: In order tor Ihe work authorized under ihis permit to be considered legal, such work must comply with all applicable codes, and all
required inapections and tinal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
WORKERS' COMPENSATION DECLARATION:
I hereby aHirm under penalty ot perjury one of the following tleclarations:
❑ I heva and will meintain a certiticete of consent to sell�lnsure lor workars' compensation, as provitled for by section 3700 of the Lebor Code, for [he pertormence of the
work lor which this permit is issued.
❑ I heve end will meintain workers' compensetion insurence, as required by section 3700 of the Labor Code, for �he peAortnence of Ihe work for which this pertnit is issued.
My warkers' compensation Insurance cartier antl policy number ere:
Cartier: Policy Number:
(This section neetl not be cromp/eretl i/ fhe peimit is veluetl af one hundred dollers ($100) oi less.)
❑ I certify ihat in ihe pe nce of the work tor w�ichy� ermit is issued, I shall not employ any person in eny manner so as to become sub�ect to Ihe workers'
compensetian laws elif mla, an ag ee 't I s�uld � come suhject to the workers' compensation proWsions ot Sectlon 3700 of the Le6or Cotle, I shell forthwith
comply with �h85e ovi5io . /�.�J
Applicant Signeture: Date:= , � � '"`7 �i
WARNING: FAILURE TO 5 RE WORKERS' COMPENSATIIXJ COVEMGE IS UNLAW FUL AND SHAIi 5UBIECT PN EMPLOYER TO CRIMINAL PENALTIES AND CMl FlNES UP TO ONE HUNDHED
TFKKISAND DOLLARE (5100,000), IN ADDITION TO THE 00.5T OF ODMPENSATION, DAAl4GE5 AS PROVIDED FOR IN SECfION 3]Ofi OF THE LABOR CO�E, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I herehy eNirm thel I am licens un r provisions of 9(com�J�� g with Section 7000) of Divislon 3 oi ihe Business end Professions Catle, entl my license is in full
torca and eHect. Lia a /� � ( /_ Class N
Conirector's Slg�ature:���Y � oa�a:�� f .— —
CONSTRUCTION LENDING AGENCY:
❑ 1 �ere�y effrtn Ihat there is a conslructian lending egency tor Ihe peAortnance of Ihe work for which ihis permit is issued. (Sec. 3097, Civil Cotle).
Lendels Name: Lenders Atldress:
Signeture: Date:
OWNER•BUILDER DECLARATIONS:
I hereby eflirtn thei untler penelry of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW tor the lollowing reeson (Sec. 7031.5, Business entl Professions
Code: Any ciry or counry which requires a pertnit to consiruct, elter, Improve, tlemolish, or repair any siructure, O�or to Its issuence, also requires tha applicant for such permit
to tile e signatl statement Ihet he or she is licensed pureuent to the prodsians of t�e Contrectors License Lew (Chapter 9(cammencing with Section 7000) of Division 3 of the
Business and Professions Code) or thet he or she is ezempt therefrom end the basis tor the alleged exemption. Any violatlon of Section 7037.5 by any applicant tor a permit
su6�ects Ihe applicent to a civ�l penalry of not more Ihan five hundred dollars (3500).):
❑ I, es owner of ihe properry, or my employees with wages es Iheir sole compensation, WILL DO TF1E WORK, end tha structure is no� intentletl or offeretl for sale (Sec.
7044, Business and Protessions Cotle: The Contractors License lew does not eDPly to en owner of properry who builds or improves ihereon, end who tloes such work
himself or herself or through his ar her own employaes, provided ihat such improvements are not intentled or oRered for sele. tl, however, the building or Improvement is
soltl within one year oi completioq Ne owner-builder wlll have the burden of proving ihet he or she dld not bulld or Improve tor purpose of sale.).
❑ I, es owner of ihe property, em EXCLUSIVELV CONTRACTING WITH LICENSED CONTRACTOFiS to construct the projeCt (Sec. 7044, Bu5ine95 end Professions
Code: The comrectors License Law does not apply to an owner of property who builds or Improves ihereon, end who contraas for such projea with e contreCtor(s)
Ilcense pursuam ro the Gontrectors License Laws.).
❑ 1 em exempt under sec. Business and Professions Code tor this reason:
Signeture: Date:
Owner ID venfied by tlnvefs license. ❑ Ves ❑ No Drivels License No. Expires:
Verificatlon of Ownership by (rype of document, i.e. - properry tax �ill or tleetl):
DIVISION OF INDUSTRIAL SAFETV PERMR CERTIFICATION:
❑ I �ereby cenity that no excavation tive (5) or more leet In depth into which a pereon is requiretl ro descend, wlll be metle in connedion with work euthodzetl Dy thls
permit, entl thai no bullding strucWre, scaHoltling, falsework, or demolition or dismantling thereot, will be mare then ihirry-six (36) feet high. (Chep. 32, Gry 2. Art 2, Sec.
347, Tltle B, Califomia Administretive Code).
❑ As owner�builtler, I will not employ anyone to tlo work which would require a permit irom Ne Division oi Intlustrlal Sefery, es noted above, unless such person has a
permit to tlo such wark from ihe division.
Signeture:
Division of Industriel Satety Permit Number:
Dete:
CERTIFlCATE OF COMPLIANCE AND AUTHORIZATON OF EMRV: I certify under penalty of perjury ihat I have read this application and stale Ihet ihe intortne�ion given is
correct. I egr omply with all state laws endy rdinances relating to building consimction, end authonze representatives ot ihe Ciry of Costa Mesa to enter upon ihe
a ve�des etl operty f� insl� � urpos 4 I a ee not to aapy or allow occupancy of any building authorized by ihis parmit until final inspedion.
awr O gal ner /` � _ /j �ate
O G 7
AnNOr Authonzed Applicant Date
COOE I INSPECTIONTYPE UAiE 11iS�ALS
7616 Fized System Finel Fire Prevention
1266
200
Pool Spa Final
Final Re-Roat
201 Finel BIaWRetaining Wall
202 � Final Feclory Fire Place
203 Final Sign
204 Finel Demolition
2406�<6
�QQE! INSPECTIONTYPE
206 Finel Mechanicel
200 Final Plumbing
210 Finel Electdcal
212 Finel Fire Prevention
220 Final Planning Approvel
222 Final Site
250 Finel Building/Occupancy
�U1�ALS
5 �'L
OWNER�I COLLEGE PARK�CO. DATE a�]_�rj(�
JOBADDRES3 2585 Greenbriar I.2riE BUILDINGPERMITNO. #�f�7�
GENERAL CONTRACTOR H31'UO2' COltSt, CO. VALUE $]_1�ZOO.00
i 57 BLOCK TRACT 2�p� Residence w/det. gar.
GROUP I& J TVPE Q ZONE RIi FIRE DISTRICT 3496
PERMITS ISSUED
INSPECTIONS DATE SUBCONTRACTOR
� _,/ / DATE I NUMBER
Trench
�ion Formsand Gradeto
to Slab
Temporary Pole
Wirinq, Rough
H ating, Final �M C S 2'd5'S% �'Z')t%��-/��-..+/ /o- �.ti S/_ J�r�G d--
ewer,House (,'pi{� Sewer,St.�yy�� i� y" O�',Q�„� �1i_y�, �„ 1'/y',�i ,5��/r%+ �
Septic Tank or Cesspool
L ng, In Out ,� ��
Final. Fixtures
Wiring,Final �R 1 l9Jl
Occupancy �R 1 1957
FORM 210 3M 10-i3
, , Vosta mesa j3uuuing Lepartment
♦. ,� "° 711 EAST 20th STREET �
�" ' COSTA MESA� CALIFORNIA
4
FOR APPLICANT TO FII.L II1T
ewm�os
Address �5g5 �reenbri ar Lane
Costa Mesa, California
Nearest
c�o55se princ ton Drive
Ownerl�n'i'Icac PATIC f:n_
irtect or
neer
-ess
ractorHfll'bOT Const.
ress Ggme
.egal Lot
cription I No. $% I Blo�
ach Metes and Bounds)
of �ot 65 x 1.05 I
New
Repair
AYYL1l;A'1'1Viv r'ulc r�tciru�
,`�4:9� BUILDiNG
� FOdi OFFICE USE ONLY
I by Date ReC'tl.' Date Iss
��'"y 16 AUG14
Costa Mesa, California
Lic. ,�( I Plans I
No. Approved
by
,,,. _ . , _ CORRECTIONS
No. of Bldga
Nowon Lot
No.of No.of
F,amilies Rooma
Demolish
`Z%
APPROVALS
ion I Inspectoi
' "'—' " '— Forms. Material:
Under-Pinning
Frame: Fire Stops,
Bracing, Bolts
I hereby acknowledge that I have read this Application
and state that the above is correct and agree to comply Lath. InA
with all City Ordinances and State Laws regulating
building construction. Lath. Ext.
Signatureaf
Permittee $ b0 onstruction ir'O. plaster, Int.
Authorized Agt. Plaster, E�ct
Valu,atlon Permit Fee $ pc � Masonry Reinforce
Plan Check $ / Bond Beam
$ 11 � 200. Total [(
Fee $ ( � '� FINAL
FORbi 204 S-BP 2bI 6-55
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