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Home My WebLink About1018 POPPY CIR - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT ,lob Address: 1018 POPPY CI Suite: Vicinity: Parcel Number: 41237305 Zoning: R1 R1 Applicant: JELENSKY, MICHAEL $0.77 Address: PO BOX 485 Other: $0.00 Phone: 714-990-4769 BREA, CA Zip: 92822-0485 Owner: THOMPSON, THOMAS WAYNE Address 1018 POPPY CIR Phone: COSTA MESA, CA Zip: 92626 Contractor: EUREKA LANDSCAPE SERVICES Address: PO BOX 485 BREA, CA Zip: 92822-0485 Arch : Address: Phone: 714-990--4769 License: 387617 Eng Address Phone: Status: ISSUED Applied: 09/27/2002 Issued: 09/27/2002 ISSUED BY: Phone: Zip: License: License: SCOPE OF PERMIT 480 SO.FT. PATIO COVER IN REAR YARD PER CITY STANDARDS. REF.: 802-01576 Plan Check: $99.61 Permit: $153.25 SMIP Res: $0.77 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $253.63 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 20- 0 PARKING Existing: 0 NOTES: FEE SUMMARY Calc Valuation: Claim Valuation: PLANNING & ZONING Rear, 0-0 Left 0-0 Right 0-0 Rear 8-0 Left 5-0 Right 5-0 Required: 0 Proposed: 0 $7,737.60 $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 a 2408-48 (800) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby aHinn 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 carrier and policy number are: Carrier: �'/MLh-T' L) IAi`S LO • Policy Number: :121A OO'D6 1146-' 02� (This section need not be completed if the permit is valued atone 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. /1,, x,01. J Applicant Signature: IA✓ll `�TA�'^�'� Date:^�2� O"). WARNING: FAILURE TO SECURE WORKER ENS TI 1 COV E IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S1O0,000), IN ADDITION THE G OF COM?' rSATION, 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. Lia II 1 Class k G '12-7 Contractor's Signature: Date: RIZ I1 O'2— 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: 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 Cade: 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: ❑ 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 builtling 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 theapplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ fJ0 (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. ......__.............................s'p........._n'tly"........._.................................................._......_..._..__.................................................t.y.................ae*'....................................................... ....................0................................................................._.. 4 If an RMPP is presently required, has Section 25534 of the California Health and Salety 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 ofthis a plication apertnil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LI No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential builtling permits). ......................................................................................... _.................. _..._............................................................................................................................................................... . e.... .......... .................................................................. ...... 8 Will any part of the facility to be constructed untler this permit be within 1000 feet from the outer boundaries of a school? ❑Yes Q �No (If ryes-, 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? ❑ Ves ❑ No ............_........._................................................................._._..................................................._....................................................................................................................................................._...................................................._........................... B (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. Sigryt ure Of L) Owner(s) Date 1127/ oZ Or Auth nz Applicant ate CODE t. INSPECTION TYPE 2&U ItITITA CODE I INSPECTIONTYPE 263 IS'lltIALS 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 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 j-4-� (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 ,lob Address: 1018 POPPY CI Suite: Vicinity: SIDE PROPERTY LINE Parcel Number: 41237305 Applicant: MICHAEL JELENSKY Zoning: R1 R1 Status: ISSUED Applied: 12/06/2002 Issued: 12/06/2002 ISSUED BY: MONA Address: i ' Phone: 714-990=4769 - . - .. Zip: Owner: THOMPSON; THOMAS WAYNE Address /1018 POPPY CIR Phone: , - COSTA MESA, CA -A Zip: 92626 . Contractor: 'EUREKA LANDSCAPE SERVICES Address: PO BOX 485-, - - / Phone:, '714-990--4769 \ � .� . •' BREAD CA " Zip: -� 92822-0485 License::: 387617 �'., - Arch, : .;/ - �.!` Eng: Address: - - - _ _ Address:-. ' : • .. - , - - -= Phone: — '� 1 `� Phone: \Zip: license: ,- "\ License: SCOPE OF PERMIT., CONSTRUCT 64 LINEAL FEET OF NEW BLOCK WALL�6 FT'IN HEIGHT OM LEFYSIDE PROPERTY LINE PER CITY STANDARDS.' - FEE SUMMARY Plan Check: $31.14 Calc Valuation:.$1,280.60• Permit: , " $47.90 -- '- - �'�' .,' Claim Valuation:�u` „ $o.00' SMIP Res:. $0.50 `SMIP Com: , $0.00 Other: $0.00 Inspection: $0.00 Total: •. $79.54 SETBACKS MAIN STRUCTURE Front 0-,0 Rear 0-0 ACCESSORY Front 0- 0� Rear 0-0 PARKING Existing:_ 0'. - Required: 0 NOTES: NG & ZONING Left - 0-0 - =-Right —0-0> Left 0-0 Right 0-01, 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) IEXPIRATION: 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 24 6-46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLATiATON: I hereby affirm under penalty of perjury one of the following declarations: ❑ . I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. �+I y workers' compdfsatlon Insurance career and policy number are: 4cardier`; i �+T NM. N) -Policy Number: �� O Opo 1141 ^ 02 J (This section need not be completed if the permit Is valued atone 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 agLee that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith plywit�ose provisions. C tAppli`nt Signature: �'Daie: 'I WARNING: FAILURE TO SECURE WORKERS' iMPENSA ERAGE U WFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000), IN ADDITIONT THE COS COMPENSAlfiefl, DAMAGES AS PROVIDED FOR IN SECTION 306 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: (I hereby affinn.that .Ia licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 ofthe Business and Professions Code, and my license is in full forceand. effect. Lic. Lclam F_J 6-2.1 Cantractocs.Signalure: Date: l 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 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: ❑ 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 Dees or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? [3 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 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 thisplication a emit for such construction or modification a from the South Coast Air Quality Management District or from any other air pollution control district or agency? � Yes 19 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......................................................................................ns-t..........................r, th.............m.i't............................................................................................................................................................................................................................................ 8 WIII any part of the laciliry to De Constmctetl untler this permit be within 1000 feel 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 ............................................................_...................................................................... ................................................................. ............ -............................................... ... .................... .... -................... ................... ............................ ........................... B (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: CERTWICATE 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. natur Of Legal Owner(s) e D �y� (r�oy A A Ihorized Ap 1 nt CODE t. INSPECTION TYPE I2AN IIS CODE# INSPECTION TYPE L18jE fWMAL$ 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 Block:/Retaining Wall (2 ger- _(( 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 Job Address: 1018 POPPY CI Suite No Vicinity: Parcel Nunmber: 41237305 Applicant: JELENSKY, MICHAEL Address: PO BOX 485 BREA, CA PLUMBING PERMIT Phone: 714-990-4769 Zip: 92822-0485 Owner: THOMPSON, THOMAS WAYNE Address 1018 POPPY CIR Phone: COSTA MESA, CA Zip:. 92626 Contractor: EUREKA LANDSCAPE SERVICES Address: PO BOX 485 Arch / Eng Address: Phone: 714-990-4769 BREA, CA Zip: 92822-0485 License: 387617 Phone: Zip: License: SCOPE OF PERMIT PLUMBING TO INCLUDE: 2 GAS OUTLETS (1-4) FOR BBQ AND FIRE PIT. REF.: B02-01575 AND B02-01576 Status: ISSUED Applied: 09/27/2002 Issued: 09/27/2002 ISSUED BY: QTY AMT FEE SUMMARY 0 AMT QTY 0 AMT ISSUE FEE $23.50 0 Laundry Tub / Washer $0.00 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 Backflow Preventer $0.00 0 P -Trap $0.00 Bathtub $0.00 0 Pressure Regulator $0.00 Clarifier System $0.00 0 Process Piping (per 10 ft) .$0.00 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 Dental Units $0.00 0 Septic Tank $0.00 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 Drain, Floor $0.00 0 - Sewer Connect $0.00 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 Drain, Roof $0.00 0 Shower $0.00 Drinking Fountain $0.00 0 Sink, bar $0.00 Expansion Tank $0.00 0 Sink, commercial $0.00 Status: ISSUED Applied: 09/27/2002 Issued: 09/27/2002 ISSUED BY: QTY AMT QTY 0 Sump Pump $0.00 0 0 Swimming Pool $0.00 0 0 Trap Primer $0.00 0 0 Urinal $0.00 0 0 Vacuum.Brkr Bkflow(1-4) $0.00 0 0 Vacuum Brkr Bkflow(5+) $0.00 0 0 Wash Basin $0.00 0 0 Wash Basin Set $0.00 0 0 Waste and Vent System $0.00 0 0 Water Closet (Toilet) $0.00 0 0 Water Heater / vent $0.00 0 0 Water Piping (Inst or Rep.) $0.00 0 0 Water Re -pipe $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 _ /e ' 244&48(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 o1 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: l"VEf ZL"S7- tiAT- 1 NS- LO- Policy Number: M50000 1 t,46-07-1 (This section need not be completed if the permit is valued a1 one hundred dollars ($100) or iess.) ❑ 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: 0112,-110 -2- WARNING' WARNING: FAILURE TO SECURE WORKERS' CC IPENSATIOt CO E 1 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 MP S ION, 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 Profess Cotle, and my license is In full force and effect. Lic. s 35-!c 1 -1 Class a Contractors Signature: Date: eI I z-r I O� 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: 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 t0 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 fora 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 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 contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Cade for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, Le. - property in 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 certify a Business Plan for emergency response to release or threatened release at 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 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. ......................._.................................................. _.............. _..............................................._.................. .............................................. ................................................... _................... ........................ ......................_.................................. .. _....... 4 If en RMPP is presently required, has Section 25534 of the Celitomia Health and Safety Code been fully complied with? ❑ Yes ❑ No .........................................__............._......................................__......................................................._.............._........................................................................................................_......................................................_.......................................... 5 Does Or w111 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- Yes 8 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 8 Will any part of the I ty to be constructed under Ihis 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 Cada). ................................._........................................................._....................._................................................................................................_._............................................................................................................................................................. 7 If a permit from the South Coast Alr Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes El 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: CERTIFlCATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and slate 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. Ail Signature Of Le Owners) /Date z d/Or Autho ed Applic t Dat O" CODE If INSPECTION TYPE PETE INTMA CODE I INSPECTION TYPE 2M It11IML9 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing _ to-a1-oa RN 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: 1018 POPPY CI Suite: Vicinity: REAR/SIDE PROPERTY LINE Parcel Number: 41237305 Applicant: JELENSKY, MICHAEL Address: PO BOX 485 BREA,CA Owner: THOMPSON, THOMAS WAYNE Address 1018 POPPY CIR Zoning: R1 R1 Phone: 714-990-4769 Zip: 92822-0485 Phone: COSTA MESA, CA Zip: 92626 Contractor: EUREKA LANDSCAPE SERVICES Address: PO BOX 485 BREA, CA Zip: 92822-0485 Arch : Address: Phone: 714-990--4769 License: 387617 Eng Address Phone: ISSUED BY: Status: ISSUED Applied: 09/27/2002 Issued: 09/27/2002 Phone: Zip: License: License: SCOPE OF PERMIT 6' HIGH X 64' L.F. BLOCK WALL ALONG RIGHT SIDE PROPERTY LINE PER CITY STANDARDS. REF.: B02-01576 Total: $79.54 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 -14 2446-06 (6/W) FEE SUMMARY Plan Check: $31.14 Calc Valuation: $1,280.00 Permit: $47.90 Claim Valuation: $0.00 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $79.54 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 -14 2446-06 (6/W) 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. tojjd 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: Ce�eia eyow'V9 N%LT - INS 4;>• P,olicy.Number..0 3S c:,00O al iVlv -+OZ) (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions Apel MTSI gnaturemat, e:> WARNING: FAILURE TO SECURE Wi COMPENSAT COVE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST" COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that l am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the.Buslness and Professions Code, and my license is In full torce.aat! 38 �P 7 Classua"a L'27 _Contractors Sigrralalpre: �Date: a a, 27 OZ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($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.). ❑ 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, Ttle 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 WIII 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 o1 500 pounds, or a volume of 55 gallons, or 200 cubic feetof 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 feel 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 fling 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 ppe plication aunit for such construction or modification from the South Coast Air Quality Management District 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). 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 Cade). ................................... _........_........._.......... _................ ....................... _....................................................................................._._..__................................... .................................... -.................... _.............................. ... _........ ......................... 7 It a permit from the South Coast Air Quality Management Distinct 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 ........................................................... _............_.................. _......................... ............................................. ....................................._._._._............................................................................................................................ ............. .- .......... .._.... B (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. / Signatu Of Legal Owners) / Date �. _ r' uthorii plicant � to--r—.m CODE t, INSPECTION TYPE Qej[ iNTITALS COPE INSPECTION TYPE 2&H (INTTTALj 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof �y 210 Final Electrical 201 Final Block/Retaining Well z� 'riL H7/" 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: 1018 POPPYCI Suite No Vicinity: REAR OF PROPERTY Parcel Nunmber: 41237305 Applicant: JELENSKY, MICHAEL Address: PO BOX 485 BREA, CA Owner. THOMPSON, THOMAS WAYNE Address 1018 POPPY CIR COSTA MESA, CA Phone: 714-990-4769 Zip: 92822-0485 Phone: Contractor: EUREKA LANDSCAPE SERVICES Address: PO BOX 485 BREA, CA Zip: 92626 Phone: 714-990-4769 Zip: 92822-0485 License: 387617 ISSUED BY: Status: ISSUED Applied: 09/27/2002 Issued: 09/27/2002 SCOPE OF PERMIT ELECTRICAL TO INCLUDE: 3 OUTLETS AND 1 SWITCH LOCATED IN BACK YARD. REF.: B02-01575 AND B02-01576 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 2aa64616roo1 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 $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 $1.10 1 ..................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 / Ckl $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 1 hp $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 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 2aa64616roo1 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. '6(( I have and will maintain workers' cornpensatlon insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. J _ My workers' compensation Insurance carder and policy number are: Carder: I=VGj"' �r N/�. IN5- CIO- Policy Number: 350000114 (e o'LI (This section need not be completed i the permit /s valued et one hundred dollars ($100) or less.) ❑ 1 certity that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions.. (r �q�`�j Applicant Signature: �Date: WARNING: FAILURE TO SECURE WORKER ' OOMPEI� SATI N CO GE IS UNLAWFUL AND SHALL SU6IECT AN EMPLOYER TO CRIMINAL PENALTI S AND CML FINES UP TO ONE HUNDRED THOUSAND DOU.ARE($/00,000), IN ADDm ON TO THECA OF COMPENSAToN, 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 k Contractors Signature: Date: q, 27 / 0-2.. 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 Coda). 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 censtruct, 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 Cade for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivels License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): 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, 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 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 Mese 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 forth 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_...............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. ...._._........._...................................__............_................._......................3-4,..o-f t'h'a.........................................................................._.._.___....................................._..... ........................_................................._........................_._... 4 If en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [_1 Yes ❑ No ..................................................................................................................... ildi........................................................................................................................................................................................................................................... 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 asp No for such construction or modification from the South Coast Air Ouelity Management District or from any other air pollution control district or agency? � Yes IJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). N%ill 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 Calffomia 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 .............................................................. _..............._..............._.................................................................................................. .....__..... ............................................. ........................................... .................................. .................... -......................... e (It yes', attach certificate of compliance from the appropriate air pollution control off !car). 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 certity 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. Sign lure Of Legal Owner(s) Dade 2T /07. nd/Or Autho a ApplicaT DAte CODE 0. INSPECTION TYPE PATE BRIDALS CODE INSPECTION TYPE GAiE INTRIA 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/Retalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.I `�•,RKERS' COMPENSATION DECLARATIIdN I .°:'•A- fi •.:' Yreby�affirm that I have a certificate of co sent to self -insure or a certificate "ti Workers' Compensation Insurance, or a certified copy ther_eot (Section ;3800, Lab: C. ) - ``-- I12;�.. - '�j� Policy No. L46 G5C'N) r. Company `� "'� ❑ Certified copy is hereby furnished. ^ 4./23/.85 TI - CITYOFCOSTAMESA ? CO STRUCTIaO�N PEF3•MIT • PERMIT,rN�O._/-� I CD T-ATCT�NO. LOT. NO. UNIT NG. Bathtubs ' Sewer Connection Cooking Unit i ' Meter ❑up to 100 amps" Project Address �_C"/ ( city Certifietl copy is filed with the city Builr}fr1�Qr�DiovV�is�loi/pp�N��'' /l �1 Data Applicant Y(-�Y�I°fy= �'�IK%SI'�I - EXEMPTION FROM WORKERS' COMPEN TION DECLARATION (Thissection need not be completed if the'permit Is'for 'one hundred ($100) or' ' less). r or ! I certify that in the performance of the work for which this permit is t to t, I employ any person in any manner so as to become subject to the Workers' 'Workers"Compensation lLaws of California.', Clarifiers I ' Solar Collectors j 'Dishwasher ' Meter El over 100 amps ¢ i + - -' - _ - - `- 1 Dishwasher Solar Pi in 1 p 9 I �D Dryers ❑Gas ❑Electric Sub Panel I Drinking Fountains Solar Tank Applicant's Mailing Addr s •� - P / ~I 'TYPE, OF CONSTRUCTION NEW ADD ALTERATION" REPAIR Floor Drains I SwimmingPool w/S aF.A.U._ - p , 'Inc. Solar ❑9-15 HP, X16-15* .,Date Signature _ Owner's Name, OkI - / mu^1•SV%hone ❑ CONVERSION -❑ DEMOLISH '❑ OTH 1 - �' A.P.# : Zone: Workers" Compensation 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' lend i n9 agency for the performance G �� Address '• /Q/,9' OPT � t^O!f *'� !.'«-d c= 'DESCRIPTION OF WORK/USEOEBLDG.-b - - S• Main 6_uild ing: J,` I Accessory_guildin - - Outlets 'Range _ _ f - ' Switches Sign ' ' Lender's Atltlress, '' 1 - I OWNER BUILDER DECLARATION Lavatories -1 - Ih Arch/Eng. License No. t TYPE OF PERMIT ,GRADING: FOUNDATION STRUCTURAL T Front - _ P -Trap _rays,Generator - O I Address - "' ❑ TENANT '❑ ELECTRICAL ❑PLUMBING ❑MECHANICAL ' B Rear ' '- v N ,vision 3of the 'Business and Professions Code) or, that he/she' is exempt and the basis for the alleged exemption. Any violation of Section nerefrom A 7031.5 by any .applicant for a i permit subjects the,.applicant to a civil .i�enalty of not more than five hundred dollars ($500). I, as, owner of, the.' property or-my'employees.with wages -as their sole compensation, will do the work, and the structure Is not intended or offered for sale,(Section 7044, Business and Professional Code; The Contractor's' License Law does not apply to an owner of a property who builds or improves thereon,,and who does such work himself/herself or through his or her own I employees, provided that such improvements are not intended or offered for . sale. If, however, the building or improvement is sold within one year -of tom- pletion, the owner will have the burden of proving he/she did not build or im- prove for the purpose of sale)'. , ❑ I, as owner of the property, am exclusively contracting with licensed con- : tractors to con5tr uct the project (Section 7044, Business and Professions Code: The Contractor's License taw docs not apply to an owner of property who builds or -improves thereon, and who contracts for such projects with con- '- ' tractor(s) license pursuant to the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section B. & P. C. for this reason Cont'ractor's Name - �� hone 1-�'201'0 -� �-ZI`3 S'1/i��/' /y �+-' �4' ❑ OTHER ' ? ° I PROJECT DESCRIPTION' SQ. FT. -I 'OCCUPANCY �l-�i A C Right .� !(`y �^ �• N G i I Address (mailing) _[l{/l� ! i CONSTRUCTIONTYPE V"il VALUATION$ II Z%' -F' S Left i 5e0 �" _ R, ; City License No. [l ( _ LICENSED CONTRACTOR DECLARATION - ' ZONE ' GRADING CU. YDS. .ACRES Ping. Ref. # - - - Parking Req./Provided o Duct -Structural I -hereby affirm that Ilam -licensed under provisions of Charter 9 (commencing Remarks:.� Planning Notes: Q ,G,p- 0 M with section ,7000) of Division 3 of the Business and Professions Code, and System Repair/Alteration - Firepl/Fact. Bit. ICBG # Fire Dampers ' my Ilcense.is in full 'forc an effect. rj ��,3 - I ; Date Owner 'I Heating System & Ducting S License Clss a o.2 - ,censey21 .2i�2 L f.S-- Signature I I - PLUMBING I FEES L 00-100,000 BTU ❑100,000BT , ELECTRICAL $ GRADING PLAN CHECK 50% $ MICROFILM •$ MECHANICAL $ TOTALFEE I$'f '• (L) 1 i PLAN CHECK 25% ;$ -- - `�•,RKERS' COMPENSATION DECLARATIIdN I .°:'•A- fi •.:' Yreby�affirm that I have a certificate of co sent to self -insure or a certificate "ti Workers' Compensation Insurance, or a certified copy ther_eot (Section ;3800, Lab: C. ) - ``-- I12;�.. - '�j� Policy No. L46 G5C'N) r. Company `� "'� ❑ Certified copy is hereby furnished. Bar Sink j Showers i ELECTRICAL .FEES • • Backflow Preventer - - - - - Service Sink -- -±- - - - - - ' -- -- -" Automatic Washer-. *Transformer ❑ 15-50.KW_ ❑ 50+ KW I -0onstruction Pole Sub. Backflow Irrigation Sewer Ca P Bathtubs ' Sewer Connection Cooking Unit i ' Meter ❑up to 100 amps" city Certifietl copy is filed with the city Builr}fr1�Qr�DiovV�is�loi/pp�N��'' /l �1 Data Applicant Y(-�Y�I°fy= �'�IK%SI'�I - EXEMPTION FROM WORKERS' COMPEN TION DECLARATION (Thissection need not be completed if the'permit Is'for 'one hundred ($100) or' ' less). r or ! I certify that in the performance of the work for which this permit is t to t, I employ any person in any manner so as to become subject to the Workers' 'Workers"Compensation lLaws of California.', Clarifiers I ' Solar Collectors j 'Dishwasher ' Meter El over 100 amps ¢ i + - -' - _ - - `- 1 Dishwasher Solar Pi in 1 p 9 I �D Dryers ❑Gas ❑Electric Sub Panel I Drinking Fountains Solar Tank 'Fan r i 1 - Motors E-1,0-1 ' Floor Drains I SwimmingPool w/S aF.A.U._ - p , 'Inc. Solar ❑9-15 HP, X16-15* .,Date Signature NOTICE: If, after making this declaration, -you should become Subject to the - - - - __ Floor Sinks �- - __ _ ..rLaundryTrays, Fixtures'- - -- - Microwave Workers" Compensation provisions of the Labor Code, you, must forthwith _ comply with. such provisions or this permit shall' be deemed revoked. CONSTRUCTION LENDING -AGENCY - ' I hereby affirm that there is a construction' lend i n9 agency for the performance t Gat Service' 'Outlets et - DeviC¢ BO%¢$ Pole,Light Interce tors ter P - - - Outlets 'Range of the work for; which- this permit is issued_(Section 3097 Civ. C_) Lender's Name ' ' ' - - Kitchen Sink - ice - - - ' Switches Sign ' ' Lender's Atltlress, '' 1 - I OWNER BUILDER DECLARATION Lavatories -1 - Ih ' r Garbage Disposal Standing Sections I I herabyiafflrmrthat 1 am exempt from the Contractor's License Law for the - following reason' (Section 7031.5 Business and Professional Code: Any city or _ P -Trap _rays,Generator - ❑0-5 KW 05-15 KW Trash Com actor Pfile count which requires a permit -to construct, alter, improve,demolish'or repair v any structure, prior to its,issuance, also requires the applicant for such permit a signed statement that he/she is licensed pursuant to the provisions ofROOF e Contractor's License Law (Chapter 9 (commencing with'Section' 7000) of" Drains s' -' 1 ,vision 3of the 'Business and Professions Code) or, that he/she' is exempt and the basis for the alleged exemption. Any violation of Section nerefrom A 7031.5 by any .applicant for a i permit subjects the,.applicant to a civil .i�enalty 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,(Section 7044, Business and Professional Code; The Contractor's' License Law does not apply to an owner of a property who builds or improves thereon,,and who does such work himself/herself or through his or her own I employees, provided that such improvements are not intended or offered for . sale. If, however, the building or improvement is sold within one year -of tom- pletion, the owner will have the burden of proving he/she did not build or im- prove for the purpose of sale)'. , ❑ I, as owner of the property, am exclusively contracting with licensed con- : tractors to con5tr uct the project (Section 7044, Business and Professions Code: The Contractor's License taw docs not apply to an owner of property who builds or -improves thereon, and who contracts for such projects with con- '- ' tractor(s) license pursuant to the Contractor's 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 - ;R¢inspeetlon Fee - Issue Fee - $ 3 i I Reinspection Fee $15 Issue'Fee $ 3 ' MECHANICAL' ' - FEES' DEVELOPMENT SE VI REQ I NTS: �� , , ' _ . Zoning Approved By Data�Ty �' Q Building Approved Application Issued ey �jl ✓I I� Date -Z � i - - Boiler + Hood Or Type I ❑ Canopy Type II' ❑ J ' Duct - Under Ground Duct -Structural Refrigeration System ❑0.100,000 BTU ❑100,000 BTU - -- - Duct - Ventilating (_ ' SUMMARY OF FEES } ,��, 50, BUILDING PERMIT -$ .J SMTP i$ I� I q r PLAN CHECK $ PERMIT ' PLUMBING ,$ ' ISSUANCE IS I - ENERGY P.C.-$ 1 PLAN CHECK 25% $ Exhaust System ❑ Multiple ❑ System Repair/Alteration Firepl/Fact. Bit. ICBG # Fire Dampers ' Date Owner 'I Heating System & Ducting Registers I ' 1 hereby. certify .that . I,have read this application and -state that the above-- information is correct. I a9re comply h all city'an county ordinances and state laws relating to bwltli n r ion, tl by out nze repre- sentatives of it e r u e a e tionetl top ty t r ,inspect io roses �/jnp 2 J Signatur DatA--? ^' Drivers' License or SS I 00-100,000 BTU ❑100,000BT , ELECTRICAL $ GRADING PLAN CHECK 50% $ MICROFILM •$ MECHANICAL $ TOTALFEE I$'f '• (L) 1 i PLAN CHECK 25% ;$ -- - • ' I ' f Reinspection Fee $15 Issue Fee $ 3 1 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor s ra _ CONSTRUCTION. AND PLA NIN ,• APPROVALS Permit#�S Date Inspector 1 _ & SPA APPROVALS Permit# Date Inspertnr 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms .4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test - 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE - 7. •Fdotings �� 58. Electrical Conduit-Undrgrnd. •,y 8. Foundaiion - 59. Gas Pipe, 0 Undrgrnd., Test ' -9.•Water Pipe-Undrgrnd. - 60. Backwash Lines, P -Trap, 0 Undrgrnd. 10. Structural Floor System - 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final " 14. Rough Plumbing. 65. Electrical -Final " 15'°Rough Electrical -Conduit 66. Solar System -Final - 16. Rough Electric Wiring 67. Fencing & Access Approval 17.. Rough Wiring Sign 68. APPROVED FOR PLASTERING - 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL - 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating - 71. Product Piping 0Gas OOil 23: Gas Pipe -Rough & Test 72. Underground Flush ' 24. Roof Framing -' - ., 73. Undergrnd. Storage Tank OGas OOil - 25. Roof Sheathing - 74. Overhead Hydro ' -26. T -Bar Ceiling (Structural) &IMonocoat 75. Dry Chemical - 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding '77. FIXED SYSTEM FINAL - 29. Insulation 78. FIRE PREV. FINAL -30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat- 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test . 36. Hood'or Canopy 37. Fidel Factory Fireplace - - - 38. Final Plumbing ,: ' 39. Water Service -Final 40. Gas Service -Final ; - 41. Sola , r -Domestic -Final 42. Backflow'Preventer r 43. Backflow Irrigation. , 44..Landscape llrripation System 45. Sound Attenuation 46. Handicap'Regulations 47. FINAL STRUCTURE'&BUILD ING' 48. Special Requirements"Completedi 49. Electric Release to Edison '-- - - 50. Gas.Release to Southern California Gas Co - 51. CERTIFICATE OF OCCUPANCY No. Date - _ - -.. - _ - t Applicant to fill in all spaces except those within 1 eclarations. y —' iCLT,Y Gf COSTA MESA PLAN 3 Elev. C .-- PERM) NO. - TRACT NO. LOT NO. - BLD - 5;I 68 3/01 /64 = 7L CGNSTRUCTION PERMIT, l LOT. 21 ��•�� Z� •- f - • _E44.26 s J P_rojec) 4ddress l ' ' TYPE OF CONSTRUCTION NEW ADD ALTERATION`• 'REPAI R - _ - APPlicarl Mailing Address I ' 1 565 t 4 ' '`'1565 e._aL -- OIOTv ❑ CONVERSION -❑ DEMOLISH - ❑ OTHER_ - _ r A.P. # - 7/ ^ 'j Zane - ...' MaeIs'sL Owner's•Name Standard Phone.SQ.��.L - ,DESCRIPTION OF WORK _ - S Main Building: - Accessory Building:- Z -- - Address. s., , _. .- - _ - -TYPE'OF PERMIT. - •GRADING FOUNDATION' ' STRUCTOJ AL T • Front' Z;y 1 J ., - , ,. ;1 0 N r - Arch/Eng ^ }$-F.� g',`ee er License No.; MAA ' ❑� TENANT ❑ ELECTRICAL El MECHANICAL ❑PLUMBING- - - B. Rears L f -0.. ❑ OTHER :. - A _ _ N Address z -�-%i� .�/--Pu'-'rls--c-rrC-�L'}� I -1"V1 R2 _•. - C r; Right y. 6 / _ • G , Contractor's Nam= �ee�Ey, _Pho_ne PROJECT DESCRIPTION SQ. FT.' �F+naoo-GCCUPANCv - Address (mailing) -CONSTRUCTION TYPE _ VALUATION $ YIIA 1710 -� $ Left " - - ' E i �./•' No.6�0 /f - ZONE - GRADING CU. YDS. 'ACRES / Ping. Ref.# - OJ 2 �� Park. Fees $ ��= O City License -7G U LICENSED CONTRACTOR DECLARATION Remarks:1 G r / c)- Parking Req./Provided I t I' hhereby'affirm that 1 am licensed' under provisions of Charter 9 (commencing 7000) of Division 3 the Business Professions Code, - Use of Building: 'C(.07ni I ' R with section of and and mY license �is In full force antl effect. License Cla'ss•l R-� ' ens' NeJ 248042 ,eQ r E Planning Notes: 1 , M I' PLUMBING - .. FEES to ' 1-12 '156-0 Signaler HOLD FOR SPECIAL ttS_ U1itEn7' S E N gar Sink Showers ,RKERS' COMPENSATION DECLARATION ae tab affirm that I have a certificate of consent to self -insure or a certificate Backflow Preventef Service Sink I , S of,Workers' Compensation -Insurance,+or -a certified. copy thereof (Section - --- - - - 3800, Lab. C.i C ` - Backflow Irrigation I SeweECap -•.�-��'i' -._ +t.; - ' ,' ELECTRICAL C -' FEES Policy No. WP -84 -LS -856 CompanrFremont 'T ndamnit - - -- B Certified copy Is hereby furnished. - , Bathtubs i Sewer'Connectibn' � _ .. __ I .. Automatic Washer f iTransformer Q 15-50:KW Certified Copy is filed with the city Builtling Division. Date 19-1 t;_R'2 Applicant __'St � Pdc1f1C Clarifiers ' - SOlar Collectors,�'� �;, '- .�-, - Construction Pole Sub. i ❑ 50+ KW l , I - EXEMPTION FROM WORKERS' -COMPENSATION DECLARATION - -- (ThisSection need not be completed If the permit i5 for one hundred ($100) or - - . t Dishwasher: 1 , -' Solar Piping P 9 � � 'Cooking Unit ; -' - ';i'-- , - - 'Meter-❑up�to-100 amps - - • less):. I certify.that in the performance of the work for,which this permit is. issued, I Drinking Fountains - - I w Solar Tank 1 , r /� . Dishwasher Meter El beer 100 amps ; shall not employ any person in any manner so as to become subject to the Workers'; Compensation Laws of California. Floor Drains-, .. Swimming Pool,w/Spa, ) Dryers ❑Gas ❑Electric 'Sub Panel Date Signature I l f I f i. NOTICE: If, after making this declaration, you should become subject to the Floor Sinks Urinal - Fan; Motors ❑0-1 HP 01'/a-8 l Workers'- Compensation -provisions of the -Labor Code, you must `forthwith - comply with such provisions. or this permit shall be l deemed revoked. - Gas Set4ice Outlets: Water Closet. ` F.A.U: +Inc Solar,❑9-15 HP 016-15+ CONSTRUCTION LENDING -AGENCY, - 1 -- - I hereby affirm that there is a construction lending agency for the performance 'C.) Interceptors - t _ Water Heater Fixturesa Microwave 1 , of the .work troy which- this, permit: is issue&. (Section .309.7- Civ. - - - _ _ , - - Lender's Name"- - _ Kitchen Sink ', j - i Water Service Device Boxes 4'Pole Light r Lender's Address- R OWNER BUILDER DECLARATION` , ': I hereby, I am from thel Contractor's for Lavatories--• I - - Outlets-. :Range , affirm,that exempt License taw the following reason (Section 7031:5 Business and Professional Code: Any city or P -Trap ' Pj c - if. 7;. Switches.. Sign county which requires a permit To construct, alter, improve, demolish or repair --ny structure, prior to its,issuance, also requires the applicant for such permit - Roof Drains - 1 1 C Garbage Disposal' Stariding'Sections `;yf ilea signed statement that he/she i9 licensed pursuant to the provisions of -_ _' '.-: Contractor's License Law (Chapter 9 (commencing with Section 7000) of ", Generator ❑05 KW ❑5-15 KW Trash Compactor I -wislon 3 of the Business and Professions Code) or. that he/she is exempt "therefrom and the basis for the alleged exemption: Any violation of Section - - 0- '7031.5 by any -applicant for a permit' subjects- the applicant to a civil Reinspection Fee„ $25 - Issue Fee - $ 3 ! - enalty of not more than five hundred dollars ($500). s Reins Fee $25 Issue Fee ' $ 3 I, n owner of thepropertyn my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered �- MECHANICAL - FEES p action _ for sale: (Section Code: The. Contractor's Business and'owner .PUB LIC SER VICES REQUIREMENT l of proper License Law does not apply to an owner f a property o'bui ltls or improves not goiter -i � '- • Ir' Hood or Type I ; - e W �3 through his or her awn hr thereon, and who does such work himself/herselfsare for that improvements intended - Canopy + Type II' ❑ Zoning Approved By Date such not or offered are not employees, ever, the sale. If, however, the or improvement is sold within one year,of com- I Duct-. Under Ground Application Approved By Date lt'hav t pletlon, the owner will have the burden of proving he/she did not build or on. Tye for the purpose of sale). I, as owner of the am exclusively contracting with licensed con- Duct - Structural 1 'r Refrigeration System *d Application Issued,By Dat property, tractors to construct the project (Section 7044, Business and Professions Code. Duct - Ventilating ❑0.100,000 BTU ❑100,000 BTU - SUMMARY OF FEES .The Contractor's License-Law-tloes not apply. to anowner. of, property who.. builds or improves thereon, and who contracts for such projects with a con- Exhaust System El Multiple ❑ System Repair/Alteration BUILDING PERMIT -$ 545 50 170 SMIP $ 10'19 tractor(s) license pursuant to the Contractor's License Law). ElI'am Section PIAN CHECK $ •• d'—ao-a� PERMIT ' exempt under B. & P. C. for this reason Firepl/Fact. Blt. ICBG+ $ PLUMBING $ .ISSUANCE Date 1 owner t Heating System & Ducting , 1. - PIAN CHECK " 1 $ i I I ENERGY'P,C. 1 $ 1 hereby certify that I have read this application and state that the above ❑0-100,000 BTU ❑100,00067- ELECTRICAL $ - ' GRADING $. Information is correct. I agree to comply with all city and county ordinances laws -- - - - MICROFILM $ antl state relating to b ilding construction; antl hereby authorize repre- sentativas o 's rj� t nte' on the above-mentioned prop rty f r inspection PLAN CHECK $ - 9`'/ MECHANICAL $ TOTAL FEE $ 17_ 44 26 Sgnatufe Date Drivers"License Or]SS - Reinspection Fee $25 Issue Fee $ 3 . . PLAN CHECK $ ' CMF 0865-46 rev. -7/83 - White Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor • CONSTRUCTION AND PLANNING - ' r - APPROVALS 'Permit -Date Inspector . &SPA - APPROVALS Permit# Date - Inspector -1. Titmporary Electrical Service or Pole . ,52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. ` c - 53.. Steel Reinforcement - - 3. Electrical Conduit Utility-Undrgrnd. - 54.1 Forms'7- 4. Electrical Conduit-Undrgrnd. - 55. Electrical Bonding .5. Steel Reinforcement .'; -• 56.- Rough Plumbing & Pressure Test - - 6! ElectricalUFER Grnd.`,' ; - ' ` 57.. APPROVAL TO.COVER-GUNITE71. 7 Footings .,58.- Electrical Conduit-Undrgrnd. 8. Foundation _ 59. Gas Pipe, 0 Undrgrnd.,- Test 9� Water Pipe-Undrgrnd. - 60.'Backwash Lines, F -Trap, 0 Undrgrnd. ' 10. Structural Floor System ., 61. APPROVAL TO DECK , 11. Property Sewer 'Line & House Connection . 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final ' 13. Roof Drains 64. Plumbing System Final 14: Rough Plumbing 65.' Electrical=Final - - 15.'Rough Electrical -Conduit - 66. 'SolarSystem=Final 16. Rough Electric Wiring - - 67. --.Fencing & Access Approval - - 17. Rough Wiring Sign 68. APPROVED,F.OR PLASTERING' 18. Rough Electrical -T Bar Ceiling 69. POOUSPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # - '20. Rough Factory Fireplace, .- 21. Ducts, in Structure - 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0Gas 0Oil 23. Gas Pipe -Rough & Test - 72. Underground Flush - 24. Roof Framing _ 73. Undergrnd. Storage Tank El Gas 00il 25. Roof Sheathing 26. T -Bar Ceiling (Structural) 9 lVlonocoat, 74.- Overhead Hydro - 75.:Dry Chemical 27-. Frame and'Hashing-' i �j�'I• 76. Dry Standpipe _ 28. Lathing & Siding 0'(3 L 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30: Drywall Nailing (ry vii HEALTH DEPT. REQUIREMENT 31. 'Plaster Brown Coat �,3,' ^L,/Li 79. FINAL INSPECTION 32. Electrical Power Meter -Final r 80. FOOD CERTIFICATE ISSUED 33. Final Electric ' Notes: 1 34. Final Heating & Air Conditioning 35. Final Gas .Pipe -Test 36. Hood or Canopy 37. Final Factory. Fireplace -- _ 38. Final Plumbing r - 39. Water Service-Flhal - 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer .43. Backflow Irrigation - - - 44. ,Landscape Irrigation System •; 45. Sound 'Attenuation - 46. Handicap Regulations 47. FINAL"TRUCTURE'&BUILDING r 48. Special Requirements Completed. ,g/29�. i 49. Electric Release to Edison - - - •- 50. Gas Release to Southern California Gas Co , 51. CERTIFICATE OF OCCUPANCY No. Date Apt b-FxoPCOSTA„M/E30 O S RU %T''I,QN. PP RIMIT Prosect Address (N"''"'� V Applicant's Mai in Addr s Owner's N/7m Address i/ Archr/Eng: - - License No. Address Contractor's Nam PhO _ Address (mailing) ��7i �I City Licencn Nn - J � L'' � LICENSED CONTRACTOR DECLARATION ' I hereby affirm that I am licensed under provisions of Charter.9 (commencing with section 7000) of Division 3 of the Business and Processions Code and my license is in full f r?ce and a tett. Lice Class 'cense No. late >y� Signature IORKERS' COMPENSATION DECLARATION ' . hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance,tor_ a. certjfigd copy thereof (Section 3800, Lab%' �� -� FY-/- Q�n� �qj Policy No Com Pant !/�u`' Certified copy is Hereby furnished. ', Cer ed co is f with the cit u din on. rROM Oat. — Applicant=7.&ktd/, 1 EX EM BTIONRKE RS' COMPENSATION DECLARATION (This section need not be completed if the permit is for one hundred ($100r or less).. , 1 certify that in the performance of the work for which this permit is issuetl, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Signature NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of .the Labor Code, you must -forthwith ' comply with such provisions. or this permit shall be deemed revoked. CONSTRUCTION; LENDING -AGENCY -t 1 hereby affirm that there is a construction lending agency for the performance of the work for .whichl this permitis, issued (Section 3097, Civ. IC.) Lender'sName - - Lender's Address OWNER BUILDER DECCARATION- ' I I hereby affirmthat1 am exempt from the Contractor's License Law for the . county Which requires a permit to construct, alter, improve, cemousn or repair zany structure, prior to its -issuance, also requires the applicant for such permit n file a signed statement that he/she is licensed pursuant to the provisions of le Contractor's'License Law (Chapter 9 (commencing with Section 7.000).of Division 3 of the Business and Professions Code) 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 , '� enalty of not more than five hundred dollars ($500). ' I, as owner of the property or' my -employees with wages as their sole 1 compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and! whodoes such work himself/herself or through his or her awn employees, provided that such improvements are notintended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im-' rove for the purpose of. sale). I, as owner of the property, am exclusively contracting with licensed con- tractorsto construct the project (Section 7044, Business and Professions Code: . The Contractor's License Law does not,apply to an owner of property who builds or improves thereon, and,who contracts for such projects with a con- tractors) license pursuant to the Contractor's License Law). Iam aware that proof of their Workers Compensation insurance should be provided to me. ❑'1 am'exempt under Section B. & P. C. for this reason Date � Owner, I hereby certify that I have read -this application and state -that the above information is cc r ct- I agree to comply with all city and county ordinances and -state laws el tmgito building con truction, antl h reby authorize repre- sentatives of i it to enter u o the be -me tioned ope y, r inspection pur Signature Dater 1 P f1 �� dP5 a 9 P lira nt to fill in all spaces except those within hea Y e r er II _ a d Sign all a ro riot¢ declarations. PF.,{{ NO. TRACT NO. LU1.70 UNIT NO. TYPE OF CONSTRUCTION NEW ADD- ALTERATION - •REPAIR '❑ CONVERSION n ❑ OTHER. q,p, # 1 I Zone DESCH IPTION 0E-WORK/USE OF BLDG: _ � _ S Main Building: - � � -Accessory-Building: ' TYPEOFPERMIT f GRADING•• E ❑.FOUNDATION ❑�STRUCTU RAL T Front - ❑ TENANT :❑ ELECTRICAL )�P PLUMBING ❑ MECHANICAL '-B Rear '-0 OTHER _ A C Right - - PROJECT DESCRIPTION, SQ. FT. t OCCUPANCY I K _ CONSTRUCTION TYPE `VALUATION$ S Left ZONE GRADING CU.YDS. 'ACRES j ping. Ref.# Parking'Req!/Provided - - Remarks: c 1 - Planning Notes: ' 0 Bar Sink Backflow Preventer- v -- - Backflow Irrigation , Bathtubs I . Clarifiers Dishwasher ' Drinking Fountains Floor Drains. Floor Sinks r - - Sink Roof Drains -Reinspection Fee I -Se .rvice Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank I Swimming Pool w/Spa, Urinal -- t Water Closet -_Water Heater Water Service - mo® Boiler Duct - Under Ground Duct -Structural Duct - Ventilating Exhaust System ❑ Multiple E Firepl/Fact. Bit. ICBG # Heating System & Ducting ❑ o-1 oo,000 BTU 0100,00013” Drivers' License or SS # - Reinspection Fee I '$15 CMF 0865-46, rev. 4/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor i Issue Fee Hood or Type I ❑ 1 Canopy Type ll ❑ Refrigeration System ❑o-100,000 BTU '❑ 1 oo,000 B System Repair/Alteration t Issue Fee Z O N I N G R E- 0 M T FEES ' ( ELECTRICAL r FEES Automatic Washer_ Construction Pole'Sub. Transformer '❑ 15;50 KW-- I ❑ 50+ KW Cooking Unit '^_' : Meter ❑up to 100 amps - _ Dishwasher _ _ Meter Dover 100 amps, Dryers ❑Gas Electric Sub,Panel Fan - Motors 1:30-1 HP ❑1'/: 8 F.A.U. Inc. Solar 09-15 HP Ell 6-15+ -- -- Fixtures - - -Microwave - - Device Boxes Pole Light Outlets i Range ' _ Switches I Sign Garbage Disposal 'Standing Sections Generator 00-5 KW 05-15 KW Trash Compactor t I i $ 3 Reinspection Fee $15 Issue Fee $ 3 FEES DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By r Date Building Approved By - Date�- Application Issued By Date_,—L� '- J _ _ BUILDING PERMIT $ PLAN,CHECK $ PLUMBING`` 5 PLAN CHEC ELECTRIC PLAN CHECK 50%, $ I MECHANICAL $ PLAN CHECK 25% $ SUMMARY OF FEES r i SMIP $ PERMIT IR RCF' a .MICROFILM $ TOTALFEE $ - - $ 3' T CONSTRUCTION AND PLANNING - ',APPROVALS Permit#'. Date Inspector - ' ?� &SPA .APPROVALS Permit # Date Inspector ' .1. Temporary Electrical: Service or Pole 52. Pool &Equipment Location - •2. Soil Pipe-'Undrgrnd. - 53. Steel Reinforcement ' 3. Electrical Conduit Utility ,Undrgrnd. 54: Forms • - ' 4. Electrical Conduit-Undrgind. - - 55. Electrical Bonding - .5. Steel Reinforcement :• r '56: Rough Plumbing & Pressure Test ' 6. Electrical UFER Grnd'_- ---i 57..APPROVAL TO COVER-GUNITE 7. Footings. N -r 58. Electrical Conduit-Undrgrnd. -t 8. Foundation 59. Gas Pipe, O Undrgrnd., Test 9. Water Pipe-Undrgrnd. ' - 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System -61. APPROVAL TO DECK - 'u 11. Property Sewer Line &House Connection _ 62.. Backwash & Receptor -Final , ' 12. Sewer Cap ' t �63. Heater &Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing - -65. Electrical -Final 15. Rough Electrical -Conduit - 66. Solar,System-Final -• 167 Rough Electric Wiring. 67.. Fencing & Access Approval 17. Rough Wiring'Sign, 68. APPROVED FOR PLASTERING 18:• Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # ' 20. Rough -Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro - 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test --, 72.-. Underground Flush 24. Roof Framing - - 73. Undergrnd. Storage Tank ❑Gas ❑Oil 25. Roof. Sheathing _ •74., Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat , 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe - 28. Lathing & Siding - 77. FIXED SYSTEM FINAL 29. Insulation - 78. FIRE PR EV. FINAL .30.Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat ' 79. FINAL INSPECTION , 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric - Notes:, I - - , 34. Final Heating'& -Air Conditioning 35. Final Gas Pipe -Test (�/yef (• 36. Hood or Canopy ' 37. Final Factory Fireplace . ' , 38. Final Plumbing lJ�Z2��tf'l ia0 39. Water Service -Final ? 40. Gas Service -Final - - - 41. Solar Domestic -Final - 42. Backflow Preventer '' • i 43. Backflow.Irrigation _ .;,,-:.:-, Y•, _ - , 44. Landscape Irrigation System _ - 45. Sound Attenuation 46. Handicap Regulations - 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed - 49. Electric Release to Edison - - •� - •--. , 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date pi . , + GITY OF -COSTA CONSTR UCTI I Address'S� bs r. Arch/Eng: ' RMIT ' No. Applicant to fill in all spacesexcept those within heavy border lines and sign all appropriate declarations. PERMIT -NO. TRACT NO. .t I LOT NO; BLD G. r TYPE OF CONSTRUCTION EW 'ADD, LJ ALTERATION —� ❑ CONVERSION ❑OEM LISH ❑•OTHER f� I -DESCRIPTION OF,WORK TYPE OF PERMIT ;GRADIN FOUNDATION 'STRUCTU _ ❑ TENANT ❑. ELECTRICAL'' PLUMBING ❑ MECHANICAL Address ❑ OTHER Contractor's Nam hone PROJECT DESCRIPTION SQ. FT. OCCUPANCY Addiess(mailing) o CONSTRUCTI ON TYPE VALUATION $: eeg� City License No. Z-1 Oq� ZONE GRADING CU.YDS. ACRES LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter;9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in ful force and effect. Li�a Q cense Class license Tte Signature R KERS' COMPENSATION DECLARATION -here by affirm that I have a certificate of consent to self -Insure -or a certificate of Workers' Compensation Insurance, or a certifieE copy thereof (Section 3800, Lab. C.) Policy No. 4 7 Ct X71 0 I -k70 Company Q< ID Certif ietl copy is hereby furnished. ( 1 ertifie co i led with the ci�'�oil Ivision. ate} � O APPIIcantT—!-.t • EXEM PTFR RKERS' COMPENSATION DECLARATION - (Thissection need not be completed if the permit is for one hundred ($100) or, less). U!, 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 t11e Workers' Compensation Laws of California. Date i Signature ' ' NOTICE: If,lafter making this declaration, you -should become subject to the Workers' Compensation provisions of the Labor Code, you .must forthwith, complywith, such provisions or _this .permit shall be deemed revoked. CONSTRUCTION, LENDING AGENCY I I hereby affirm that there is a construction lending agency for the performance of the 'work for which this permit is issued (Section 3097 Civ. CJ, Lender's, Name: _ Lender's Address• OWNER BUILDER DECLARATION - "2refrom 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 enalty of not more than five hundred dollars ($500). • I, as owner of the property or my employees with wagei as their sole Remarks: Bar Sink Backflow Preventer Backflow Irrigation Bathtubs Clarifiers Dishwasher Drinking Fountains Floor Drains Gas Service. Outlets' Interceptors Kitchen Sink, - Lavatories P—.Trap Roof.Drains. - Reinspection Fee '$25 cc m pensatlon will do the work, and the structure Is not Intended or offered for sale (Secflon 7044, Buslneas and. Professional Code:i The' Contractor's Sub Panel j Fan -' " Motors 1:10-1 HP ❑1 h"= 6 -'' _ License Law does not apply to an owner of a property who builds or Improves thereon, and who does such work'himselt/herself or through his or her own Fixtures Boiler Device Boxes Dupt - Under GlPu od employees, provided that such Improvements are not intended or offered for .sale. If, however, the building or Improvement is sold within one year of com- pletion, the owner will%have the burden of proving he/she did not build or Ini rove for the purpose of sale). : Switches Duct -Structural , I, as owner of the property, am exclusively contracting with licensed con- ,tractorsto construct the project:Section 7044, Business and Professions Code:"'. =s ._ Duct - Ventilating ' The Contractor's License Law not apply to an owner of property who builds or Improves thereon, and who contracts for such projects with a con- tractor(s) license pursuant to the Contractor's License Lawl. ❑ I am exempt under Section - B. & P. C. for this reason i Exhaust System ❑ Multiple ❑ Date Firepl/Fact. Bit. ICBG # Date owner 'I hereby certify that Phave read -this application antl 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 repre- sentatives of this(cityl to enter- Ipon the above-mentioned pro art for Inspection P r a Signature Date Drivers' LI<ense or s5 YA Heating System & Ducting ❑0.100,000'BTU 0100,000BTI Date - Reinspection Fee $25 CMF 0865-46 rev. 12/83 White - Building;Canary - Applicant; Pink- Accounting; Goldenrod - Assessor Showers Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimming Pool w/Spa Urinal ' Water Closet m MR A.P. # S Main Build E" T Front B Rear A C Right K S Left '.Ping. Ref. # Parking Req./Pr Use of Building ES. Planning Notes: Water -Heater Water Service - Issue Fee . $ 3' Hood or Type I ' ❑ itr Canopy Type 11 ❑ 10rigeration System I r: 1. �0-100,000BTU ❑100,000BTIU System Repair/Alteration Issue Fee I $- 3 i Automatic Wsher Construction Pole Cooking Unit 5764''3L09/84 40:50 TL Zone Accessory Building: - Z N I Ni G R E Park.Fees $ _ Q U R E , , M E N T S ELECTRICAL FEES Transformer ❑ 15-50 KW ❑ 50+KIN Meter El up to 100 amps Meter Dover 100 amps Dryers ❑Gas ❑Electric Sub Panel j Fan -' " Motors 1:10-1 HP ❑1 h"= 6 -'' F.A.U. Ina Solar ❑9-15 HP 016-15+ Fixtures Microwave Device Boxes Pole Light Outlets i Range Switches Sign ( Garbage Disposal i 'Standing Sections Generator ❑0.5 KW 05-15 KW Trash Compactor _ Reinspection Fee $25 Issue:Fee $ 3 PUBLIC SERVICES REQUIREMENTS: Zoning Approved By Date 1 Building Approved, By Date - Application Issued By - Date ' • SUMMARY OF FEES Z BUILDING PERMIT '$ SMTP' $ PLAN CHECK ,' ,$ PERMIT i PLUMBING .$3 "�-• ISSUANCE 1$ r ENERGY P.C. 1$ PLAN CHECK 25% $ ELECTRICAL $GRADING, $ ' PLAN CHECK - 50% '$ MICROFILM $ MECHANICAL i '$ - TOTALFEE 1$ = PLAN CHECK 25% , $ - - I F '�'_CONSTRUCTION AND PLANNIN .-r _ - PO !-SPA ./ Date• . APPROVALS Permit* InspectorDate APPROVALS - Peimlt:+ - 'Inspector; f. -Temporary -Electrical Service or Pole 52. Pool &-Equipmerii Location ' .. 2. 'Soil Pipe-Undrgrnd. - 3 id�8�t (�Q -53: Steel Reinforcement- - ='^' I ,�•� - 3: Electrical Conduit Utility-Undrgrnd.' ! 54. -Forms - .. - :7_' •'' "�_ , _ 4- Electrical Conduit-Undrgrnd, , , 55. Electrical Bonding• r u � • 5. Steel Reinforcement) 56. Rough Plumbing & Pressure .Test_, 6. Electrical UFER Grndt•� - -. •_ 57: Applicant to fill in all spaces except those within heavy ,_CITY.OF COSTA MESA C0,NSPERMIT ; PERMIT Nn- / TRACT NO. Project Address 1O`$ - P" Applicant's Mailing Address - Owner's Name— Phone Address Arch/Eng. License No. Address Contractor's Name ;Phone Address (mailing) City License No. - LICENSED CONTRACTOR DECLARATION 1 hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and professions Code, and my license is in full force and effect. License Class_ License No. Date Signature WORKERS' COMPENSATION DECLARATION I hereby'affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Lab. C.) Policy No. Company eCertified copy is hereby furnished. Certified copy is filed with the city Building Division. Date - Applicant EXEMPTION FROM WORKERS' COMPENSATION DECLARATION (Thissection need not be completed if the permit is for one hundred ($100) or ess) 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, Date Signature NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. 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 (Section 3097 Civ. C.) Lender's Name L.mler's Address OWNER BUILDER DECLARATION I hereby affirm that I amexempt from the Contractor's License Law for the following reason (Section -7031.5 Business and Professional 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/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt 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).. LJ I, -as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intendedor offered for sale (Section .7044, Business and Professional Code; The Contractor of 'a Law does not apply to an owner oa property who builds c impro es thereon, and who does such work himself/herself or through his or her o employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- rave efor the purpose of sale). I, aS,owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: -The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor(s) license pursuant to the' contractor's License Law). I am aware that proof off their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section B. & P. C. for this reason Date Owner . I hereby certify that I have read information is correct. I agree to c and state laws rel to building sentatives of th" iI to enter inspection Pur e;,. �O J State that the above and county ordinances iereby authorize repre- rntloned , property for //J —7 2—N and sign all appropriate declarations. TYPE OF CONSTRUCTION LJ NEW LJ ADD - ❑ CONVERSION "❑ DEMOLISH ❑ OTHER DESCRIPTION OF WORK/USE OF BLDG. LJ ALTERATION LJ REPAIR - - SUMMARY OF FEES BUILDING PERMIT $ SMIP $ PLAN CHECK $ PERMIT PLUMBING $ IS -OCA ISSUANCE $' PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL $ GRADING $ PLAN CHECK 50% $ MICROFILM $ MECHANICAL $ TOTAL FEE $ PLAN CHECK 25% $ A.P. + S Main Building:' IDSTRUCTURAL TYPE OF PERMIT LJ G::: ADNG FOUNATION ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL ❑ OTHER, T Front " A Rear - C Right PROJECT DESCRIPTION Sq: FT. OCCUPANCY CONSTRUCTION TYPE VALUATION $ ZONE GRADINGCU.YDS. :ACRES KLeft S Ping. Ref.+ Remarks: 1 Planning Notes: - Bar Sink Backflow Preventer Backflow Irrigation Bathtubs i Clarifiers Dishwasher Drinking Fountains Floor Drains Floor Sinks - Gas Service Outlets Kitchen Sink " Lavatories " P—Trap Roof Drains i • Reinspection Fee- $15 Duct - Under Ground Duct - Structural Duct -Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact: Blt. ICBG # Heating System & Ducting ' ❑0-100,000 BTU 1:1100,000 BTi Driver icense or SS � / I I Reinspection Fea $15 CM 0865-46, rev. 4/84 -Applicant; Pink -Accounting; Goldenrod -Assessor Showers Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimming Pool w/Spa Urinal Water Closet Water Heater -Water Service ' Issue Fee ANrfCAL r Hood or Type ❑ Camopy_ Type I I ❑ Refrigeration System ❑0-100,000 BTU '❑ 100,000 System Repair/Alteration Issue Fee - Automatic Washer." _ Constructior• Pole Sub. Cooking Unit Dishwasher ' Dryers ❑Gas ❑Electric Fan F.A.U. Fixtures - - Device Boxes Outlets Switches Garbage Disposal Generator ❑0.5 KW ❑5- 5 K 0445 10/17/84 Zone - Accessory Building: Transformer -IJ- 15-50 KW ❑ 50+KIN Meter LJup to 100 amps Meter ❑over 100 amps Sub Panel ' Motors ❑0.1 HP ❑l% - Inc. -Solar 09-15 HP ❑16-15+ Microwave- - Pole Light Range Sign Standing Sections Trash Compactor $ 3' Reinspection Fee $15 Issue Fee FEES DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By Building Approved By Application Issued By 155.00 TL, FEES $ 3 Z O N I N G R E O T S. SUMMARY OF FEES BUILDING PERMIT $ SMIP $ PLAN CHECK $ PERMIT PLUMBING $ IS -OCA ISSUANCE $' PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL $ GRADING $ PLAN CHECK 50% $ MICROFILM $ MECHANICAL $ TOTAL FEE $ PLAN CHECK 25% $ $ 3 r". CONSTRUCTION AND PLANNING 'APPROVALS. Permit # Date 7 Inspector - POS sr SPA APPROVALS Parm it# - Date 'Inspector. 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54: Forms 4, Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test - - '16. Electrical UFER Grnd. - 57. APPROVAL TO COVER-GUNITE1. 7. -Footings 58. Electrical Conduit-Undrgrnd. B. Foundation 59. Gas Pipe, 0 Undrgrnd.; Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, 0 Undrgrnd. 10. Structural Floor System 61. APPROVALT.O:DECK - .' 11. Property Sewer Line & House Connection 62. Backwash &Receptor -Final 12. Sewer Cap - 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final ' 14. Rough Plumbing 65. Electrical -Final • 15. Rough Electrical -Conduit - 66. Solar System -Final - - 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign -• 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT • APPROVALS 'Permit # . 20. Rough Factory Fireplace 21.- Ducts, in Structure 70. Underground Hydro " 22. 'Ducts, Ventilating 71. Product Piping 0 Gas 'O Oil - 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing - 73. Undergrnd. Storage Tank 0Gas 0Oil 25. Roof Sheathing 74. Overhead Hydro _ 26. T -Bar Ceiling (Structural( & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe - 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL .30. Drywall Nailing HEALTH DEPT. REQUIREMENT , 31. Plaster Brown Coat 79. FINAL INSPECTION " 32. Electrical Power Meter -Final .80. FOOD CERTIFICATE ISSUED - . 33. Final Electric Notes: 34. Final Heating & Air Conditioning t , 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace - 38. Final Plumbing Jta%1Zr,f (.EO ' 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final ' 42. Backflow Preventer - 43. Backflow.,lrrigation .... 44. Landscape Irrigation System } 45. Sound 'Attenuation - 46. Handicap Regulations , 47. FINAL STRUCTURE•&BUILDING 48. Special Requirements Completed 49. Electric Release to Edison - - - 50. Gas Release to Southern California Gas Co 51. CERTIFICATE,OF OCCUPANCY No. Date _ t Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. WWOF COSTA MESA CONSTRUCTION PERMIT Project Address 1018 Poppy Circle Applicant's Mailing Address - - Owner'sName Standard Paciffir Cnrp—PhoneS46-1161- Address 1565 W MacArthur Costa Mesa 92626 Arch/Eng.. License NO.' _ Address - - Cont'ractor's Name New- Plumbing ' 'Phone528—'1140 . Address (mailing).- 7109 N Fee Ana 'Anaheim City License_2 No. 2871 CONTRACTOR ONTRACTOR DECLARATION I hereby affirm that I am licensed under provisio,!P.6_Z7rf�� arter 9 (commencing with section 7000) of Division 3 of the Busin s antl Vrofessions Code, and my licensefs in full fte ]Ar� effect. License Class `�-3b Lic se No. 426109 Date 10/10/A4 �..Signature ' WORKERS' COMPENSATION DECLARA I hereby affirm that I have a certificate of consent to self -insure or a certificate " _of Workers' Compensation Insurance, or a certified copy thereof (Section _ 3800,Lab. - Policy No. P`WC-1777141 company HOroe Certified copy Is hereby furnished. ' yR�rSSljiytl rip py is filed with the city B ildingp�vI iqn, I t U/ Ill/i14 Applicant IVP -W Fr IU Ai EXEMPTION FROM WORKERS' COMPENSATION DECLARATION (This section need not be completed if the permit is for one hundred ($100) or less): 1 certify that in the performance ofthe work for which this permit is issued, shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws California. Date -Signature NOTICE: CompensationIt, after making this ions f on, you should become subject to the Workers'.with- such provisions r 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 agency for the performance' of the work for which. this permit is issued 3097 Civ. C.) Lender's Name Lender's Addmss OWNER BUILDER DECLARATION - I hereby affirm that I am -exempt from the Contractor's License Law for the following reason (Section -7031.5 Business and Professional 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 assigned statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter,9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt rherefrom 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 enalty of not more than five hundred dollars ($500)., L. as owner of the property or my employees -with wages as their Sole co mpensation, will do the work, and the structure isnot intended or offered , for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not,intended or offered for sale. If, however, the building or improvement is sold,within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- 1M�1e for the purpose of sale). U I, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor(s) license pursuant to the Contractoi's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me.' ❑ 1 am exempt under Section B. & P. C. for this reason Date Owner I hereby certify that I have -read this application and state that the above information is correct. agree to erm, with all city and county ordinances and state laws relating to build <Oof ruction, and hereby authorize repre- sentatives of this city to an er up !f the above-mentioned -property for inspection Issrr�L6 Lo Signature 3i '"-" J'�1••— -[� I I Reinspection Fee CMF 0865-46, rev. 4/84 White - Building; Canary - Applicant; Pink -Accounting; Goldenrod - Assessor $15 i FEES Hood or Type ❑ Canopy Type I I ❑ Refrigeration System ❑0-100,000 BTU 0100,000BTU System Repair/Alteration Issue Fee 1 $ 3 A.P. # S Main Building: E T FrontB. _ A Rear _ C Right K S Left Ping. Ref. # Planning Notes: Automatic Washer-' Construction Pole Si Cooking Unit Dishwasher Dryers ❑Gas OF Fan F.A.U. Device Boxes Outlets Switches Garbage Disposal Generator ❑0-5 KW ❑5-15 01.88 10/12/84 Zone Accessory Building: Parking Req./Provided - ELECTRICAL Transformer ❑ 15-50 KW ❑ 50+KW . Meter ❑'up to 100,amps Meter ❑over 100 amps Sub Panel 'Motors ❑0-1HIP Ell '/:-8 ' Inc. Solar 09-15 HP 1:116-15+ Microwave Pole Light Range Sign Trash Compactor 5,50 TL Z O N I I N G R E Q' M AT S. FEES - Ili Reinspection Fee $15 Issue Fee $ 3 DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By Date Building Approved By , Date Won Issued By ' Dat 2.- ' SUMMARY OF FEES I BUILDING PERMIT $ SMIP $ PLAN CHECK $ PERMIT PLUMBING $Irl6_0 ISSUANCE $ PLAN CHECK 25% $ ` ENERGY P.C. $ ELECTRICAL $ 'GRADING $ PLAN CHECK 50% $ MICROFILM $ MECHANICAL $ TOTALFEE $ -_ 56L PLAN CHECK 25% $ CONSTRUCTION AND PLANNING ;. APPROVALS Permit # 7Datelnspector PO, & SPA - - -APPROVALS •Permit # " Date . • Inspector :1. Temporary Electrical Service or Pole 52. Pool & Equipment Location { 2. Soil Pipe-Undrgrnd. 53. -Steel Reinforcement - { 3. Electrical Conduit Utility-Undrgrnd. 54. -Forms - �• 4. Electrical Conduit-Undrgrnd. 55. -Electrical Bonding 5. Steel Reinforcement p - 56. Rough Plumbing & Pressure Test 6. Electrical UFERGrnd. 57. APPROVAL'TO COVER-GUNITE .7.- Footings yi 58. Electrical Conduit-Undrgrnd.; '8. Foundation 'i;•:' 59. Gas Pipe, O Undrgrnd., Test 1 w 9. Water.Pipe-Undrgrnd. 1 - 60., Backwash Lines, P -Trap, 0 Undrgrnd. •1. 10. Structural Floor System-� '�- 61. APPROVAL TO DECK - - J 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final ,'. r. r 13. Roof Drains 64. Plumbing System - Final - 14. Rough Plumbing 65. Electrical -Final i 15. Rough Electrical -Conduit , - - - .66. Solar System -Final- - - 16.' Rough Electric Wiring- `67. Fencing & Access Approval - - 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough. ElectricaI-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure. 70. Underground Hydro- ydro22. 22.Ducts, Ventilating o 71. Product Piping O Gas OOil 23. Gas Pipe -Rough & Test' - - 72. Underground Flush- - - 24. Roof _Framing 7 73..Undergrnd.StorageTank 0Gas OOil 25. Roof Sheathing •• 74. Overhead Hydro 26. T -Bar Ceiling'(Structural) & Monocoat 75. Dry Chemical _ 27.'Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding , 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL .30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION -- - 32. Electrical Power Meter -Final 80; FOOD CERTIFICATE ISSUED ' 33. Final Electric Notes: 34. Final Heating &Air Conditioning 35. Final Gas Pipe -Test - 36. Hood or Canopy - - 37. Final Factory Fireplace 1 38. Final Plumbing, 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final .- 42. Backflow Preventer - ,y 43. Backflow Irrigation f, rT 44..Landscape Irrigation System 45. Sound _Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE.& BUILDING 48. Special Requirements Completed i 49. Electric Release to. Edison - -- 50. Gas Release'to Southern California Gas Co n 51. CERTIFICATE OF OCCUPANCYNo. Date I Y OF COSTA M SA u IV Project Address MY Applicant's Mailing rens Owner's Nam / Address 1 n Arch/Eng. W Address Contractor's Name Address (mailing) - r� City License_ No. / LICENSED CONTRACTOR DECLAI I hereby affirm that I am licensed On with section 7000 of Division 3 of my licensefis id fuo(a0 a)-ld effect. PERMIT Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. PERMIT NO._ I TRACT NO. LOT b104 I UNIT N= ION provisions of Charter 9 (commencing Business and Pr esSiogs C: a71tl lxl .:Date Signature .'?WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to s If -insure ora certificate Of Workers' Compensation Insurance, or a certifie vcoofpy thereo (Section 3000, Lab. �,t�� ri/� Policy No. Company Company 8 Certif ie co y is re w furnis hetl. Certs ' iletl with the city Buil Oat e ' Applicant U EXEMPTION FRO WORKERS -COMPENSATION IdECLARATION (Thissection need not be completed if the permit is for one hundred ($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' CompensationLaws of California. Date Signature NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation 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 �s a Construction lending agency for the performance of the work for w�permiI is issued (Section 3097 Civ. C.)is issued (Section 3097 Civ. C.) Lender's Name or Lender's Address - OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional 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/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt 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 Enalty 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 (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and whodoessuch work himself/herself or through his or her own employees, provided that such improvements are notlintended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- r�rove for the purpose of sale). LJ I, as oWn¢r of the property, Se exclusively contracting with licensed Con- tractorsto construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con-- tractor(s) license pursuant to the Contractor's License Law). Iam aware that proof of their Worker's Compensation insurance should be provitletl to me. ❑ 1 am exempt under Section B. & P. C. for this reason Date Owner, I hereby certify that I have read information is c ct. I agree to < and state laws toting to but Win, sentatives of is city to enter Inspection pu Signature Drivers' License or SS �r CMF 0865-46, rev. 4/84 White - I lication and state that the above Ith all city and county ordinances :tion and hereby autho lze refire- t e ab ve-mentioned pr pkat Qfo Date �'� TYPE OF CONSTRUCTION LIKNEW LJ ADD LI ALTERATION LJ REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER DESCRIPTION OF WORK/USE OF BLDG. .- — PLUMBING A.P. S Main Building: FFFF��IIII TYPE'OF PERMIT GRADING ❑ FOUNDATION/u STRUCTURAL _ ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING HMECHANICAL • OTHER T B A Front Rear Sewer Connection PROJECT DESCRIPTION SO. FT.OCCUPANCY' CONSTRUCTION TYPE • VALUATION $ ZONE GRADING CU.YDS. ACRES C Right KLeft $ Drinking Fountains Ping. Ref. # Remarks: I// -A) _71' Planning Notes: ES 1—] Reinspection Fee ` $15 1 1 Issue Fee $ 3� MECHANICAL FEES 1 .- — PLUMBING 3ar Sink Showers - 3ackflow Preventer_ - Service Sink 3ackf low Irrigation Sewer Cap 3athtulisy- Sewer Connection Clarifiers Solar Collectors Dishwasher ^ Solar Piping Drinking Fountains Solar Tank Floor Drains Swimming Pool w/Spa Floor Sinks Urinal Gas Service :Outlets, Water Closet ' Interceptors - Water Heater Kitchen Sink Water Service Lavatories P—Trap Roof Drains ' ES 1—] Reinspection Fee ` $15 1 1 Issue Fee $ 3� MECHANICAL FEES 1 �� I Reinspection Fee�$15 Canary -Applicant; Pink -Accounting; Goldenrod - Assessor Issue Fee $ 3 Automatic Washer- -- '� Construction Pole Sub. Cooking Unit Dishwasher , Dryers ❑Gas ❑Electric Fan ` F.A.U. Fixtures Device Boxes Outlets Switches Garbage Disposal Generator 00-51<W 05- Reinspection 5- 3606 7/06/84 Zone Accessory Building: Parking Req./Provided ELECTRICAL Transformer ❑ 15-50 KW ❑ 50+ KW Meter ❑up to 100 amps Meter ❑over 100 amps Sub Panel Motors 00.1 HP ❑l % - R Inc. Solar 09-15 HP El 16-15+ Microwave Pole Light Range 5 K Reinspection Fee IIReinspection Fee $155 DEVELOPMENT SERVICES REQUI Zoning Approved By Building Approved By Application Issued By C 9.25 TL' FEES Standing Sections Trash Compactor Issue Fee $ 3 JTS: { SUMMARY OF FEES . BUILDING PERMIT $ SMIP $ PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE $ _ PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL $ GRADING $ PLAN CHECK 50% $ MICROFILM $ MECHANICAL $ f TOTAL FEE PLAN CHECK 25% $ Z O N I N G R E; Q M T S. Boiler Hood or Type I ❑ Canopy TYPe I El Duct - Under Ground Duct -Structural Refrigeration System 00-100,000BTU 0100,000BTU Duct - Ventilating Exhaust System ❑ Multiple ❑ System Repair/Alteration Firepl/Fact. Bit. ICBO # r 1 Heating System & Duct' i 0-100.000 BTU 00.00(18T 1:10-100.000_ �� I Reinspection Fee�$15 Canary -Applicant; Pink -Accounting; Goldenrod - Assessor Issue Fee $ 3 Automatic Washer- -- '� Construction Pole Sub. Cooking Unit Dishwasher , Dryers ❑Gas ❑Electric Fan ` F.A.U. Fixtures Device Boxes Outlets Switches Garbage Disposal Generator 00-51<W 05- Reinspection 5- 3606 7/06/84 Zone Accessory Building: Parking Req./Provided ELECTRICAL Transformer ❑ 15-50 KW ❑ 50+ KW Meter ❑up to 100 amps Meter ❑over 100 amps Sub Panel Motors 00.1 HP ❑l % - R Inc. Solar 09-15 HP El 16-15+ Microwave Pole Light Range 5 K Reinspection Fee IIReinspection Fee $155 DEVELOPMENT SERVICES REQUI Zoning Approved By Building Approved By Application Issued By C 9.25 TL' FEES Standing Sections Trash Compactor Issue Fee $ 3 JTS: { SUMMARY OF FEES . BUILDING PERMIT $ SMIP $ PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE $ _ PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL $ GRADING $ PLAN CHECK 50% $ MICROFILM $ MECHANICAL $ f TOTAL FEE PLAN CHECK 25% $ Z O N I N G R E; Q M T S. -A. . CONSTRUCTION AND PLANNING APPROVALS Permit # _ - Date - Inspector' _ L & SPA APPROVALS : Permit 4- - Date Inspector 1. Temporary Electrical Service or Pole - . - 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. - 53.. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. . 54. Forms" -4. Electrical Conduit-Undrgrnd.= - - 55. ' Electrical'Bonding 5. Steel Reinforcement r _ _ 56.; Rough Plumbing & Pressure Test t •: 6. 'Electrical UFER Grnd. a :. 57. APPROVAL TO COVER-GUNITE 7, Footings& I - - 58. Electrical Conduit-Undrgrnd. - - 8: Foundation , ', - - 59. Gas Pipe, 0 Undrgrnd., Test - - _9. Water'Pipe-Undrgrnd. - 60. Backwash Lines, P-Trap,.0 Undrgrnd. 10. Structural Floor System - .61. APPROVAL TO DECK 11. Property�Sevver Line & House Connection 62. Backwash & Receptor -Final - 12. Sewer Cap - 63. Heater & Vent -Final ' 13. Roof Drains - -_ _ 64. Plumbing System - Final - 14. Rough Plumbing 65. Electrical -Final - 15. Rough Electrica l -Conduit. -- - 66: Solar System -Final, 16. Rough Electric Wiring 67. Fencing & Access Approval - 17.Rough Wiring Sign- 68. APPROVED FOR PLASTERING - 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL - 19. Rough Heating & Air Conditioning 7/��/�i� Lfp FIRE DEPT. REQUIREMENT APPROVALS . Permit# 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22: Ducts, Ventilating 71. Product Piping 0Gas El Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof .Framing 73. Undergrnd. Storage Tank OGas 0Oil 25. Roof Sheathing - 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 1 75..Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT - 31. Plaster Brown Coat 79. FINAL INSPECTION ' 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning 4( 35. Final Gas Pipe -Test - 36. Hood or Canopy - 37. Final Factory Fireplace , 38. Final Plumbing, I ' 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final r.. 42. Backflow Preventer r 43. Backflow Irrigation 44. Landscape Irrigation System , 45. Sound Attenuation ' 46. Handicap Regulations ' 47. FINAL STRUCTURE & BUILDING - 48. Special Requirements Completed 49.•Electric Release to Edison - - -• 50. Gas Release to Southern California Gas Co ' 51. CERTIFICATE OF OCCUPANCY - No. - Date ° .- - 1111"i I • A011411) __0) Applicant to fill in all spaces except those within heavy border lines and sign all CITY -OF COSTA MESA CONiIiW T OVA-' RMIT Project Address A��'� �� ✓ Applicant's Mailing Address Owner's Name Phone Address ^.r % - Arch/Eng License No. Address Contractor'[ Nam Address (mailing) City License No. LICENSED CONTRACTOR DECLARATION I`hereby'affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code and my license is in fuyorceppp effect. _ i7 J L ffAA— VORKERS- COMPENSATION DECLAWA-f16N - hereby affirm that I have a certificate of consent to self -insure or a certificate .if Workers' Compensation Insurance, or a certified copy -thereof (Section 3800, Lab. C�-.7 / � � D Policy No. Company ❑ Certified copy is hereby furnishetl. DDate�ertifiep cop iletll h the city B din 110 CtN ei Applicant EXEMPTION— FROM RS' COM E ATION E RA — ION (This section need not be completed if the permit is for one hundred ($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. Date 'Signature NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation 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 which this permit is Issued (Section 3097 Civ. 'C.) Lender's Name Lender's Address OWNER BUILDER DECLARATION- ' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional 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/she is licensetl; pursuant to the provisions of he he License Law (Chapter 9 (commencing with Section 7000) of ivision 3 of the Business and Professions Code) or that he/she is exempt ,ierefrom 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 enalty of not more than five hundred dollars ($500). 1, as owner of the property of my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- ULJve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed con- tractorsto construct the project (Section 7044, Business and Professions Code: The Contractor's , License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor(s1 license pursuant "to"the Contractor's License Law). I am aware that proof off their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section B- & P. C. for this reason Date Owner I hereby certify that I have reiu information is correct. I agree to and state laws relating bu" in sentatives of this cit to ter inspection purposes. Signature Drivers' License or SS this above date declarations. NO. ,. 3013 6/27/84 TYPE OF CONSTRUCTION LJ NEW Ll ADD ALTERATION EJ REPAIR ❑ CONVERSION ❑ DEMOLISH '❑ OTHER A.P. # DESCRIPTION OF WORK/USE OF BLDG. _ S Main Building: Accessory Build TYPE OF PERMIT GRADING ❑ FOUNDATION 0 STRUCTURAL T Front ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL A Rear ❑ OTHER C Right -- PROJECT DESCRIPTION SQ. FT. OCCUPANCY—K- . CONSTRUCTIONTYPE VALUATION$ S Left ZONE GRADING CU.YDS. ACRES Plug. Ref. # Parking Rey./Pr Remarks: . , 1 . /�9 Planning Notes: Sink Preventer Irrigation Dishwasher l Drinking Fountains Floor Drains Floor Sinks - Gas Service ' Outlets Interceptors Kitchen Sink Lavatories_ P—Trap Roof Drains -' Reinspection Fee" . ' 1 $15 Boiler Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple Firepl/Fact. Bit. ICBO # Heating System & Ducting ❑0-100,000 BTU ❑ 100,000 ' I I Reinspection Fee 1 $15 CMF 0865-46, rev. 4/84 White - Building; Canary - Applicant; Pink -Accounting; Goldenrod - Assessor Zone 83.85 TL' FEES' $ 3 Z O N I N G R E Q M T S. IMBING" FEES Showers ELECTRICAL - Service Sink -' Automatic Washer - Construction Pole Sub. Transformer ❑ 1S-50'KW- ❑ 50+KW Sewer Cap Sewer Connection Cooking Unit Meter ❑up to 100 amps Solar Collectors Dishwasher Meter JZ�dver 100 amps Solar Piping Dryers []Gas ❑Electric Sub Panel Solar Tank Fan Motors 1:10-1 HP IDIA - 8 Swimming Pool w/Spa F,A.U. Inc.Solar 1:19-15 HP 1:116-15+ Urinal Fixtures - Microwave Water Closet - Device Boxes Pole Light -Water Heater XZ Outlets Range Water Service Switches Sign Garbage Disposal Standing Sections Generator ❑0-5 KW 05-15 KW Trash Compactor Issue Fee $ 3 Reinspection Fee $15 Issue Fee AANICAL FEES DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By Date— Building Approved By Date_ Application Issued By Date -1 Hood or Type 1:1 Canopy Type I I El ' Refrigeration System ❑0-100,000 BTU ❑100,000 BTU , BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL PLAN CHECK 25% SUMMARY OF FEES $ SMIP $ _ $ PERMIT $ ISSUANCE $ - $ ENERGY P.C. $ _ $ ee'y/J/1 GRADING $ _ $ 2 -L' -.L_! MICROFILM $ _ $ TOTALFEE $ _ $ System Repair/Alteration Issue Fee $ 3 83.85 TL' FEES' $ 3 Z O N I N G R E Q M T S. -CONSTRUCTION AND PLANNING APPROVALS, Permit # Data ,r Inspector PO. t SPA APPROVALS Permit # Date - In 1. Temporary Electrical Service or Pole. 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd., 53. Steel Reinforcement - 3,_Electrical Conduit Utility-Undrgrnd., 54. Forms 4..Electrical Conduit-Undrgrnd. _ i 55. Electrical Bonding 5. Steel Reinforcement r. 56. Rough Plumbing & Pressure Test • �Y �' 6• rElectrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE C fr 7., Footings _ 58. Electrical Conduit-Undrgrnd. 8. Foundation . 1 ` %� - 59. Gas Pipe, O Undrgrnd., Test ' " r- 9.,Water Pipe-Undrgrnd. '/. ,> , 60. Backwash Lines, P-Trap, Undrgrnd. 10. Structural Floor System = r 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection . '" h 62. Backwash &Receptor-Final 12. Sewer Cap - _, .• c° /. - 63. Heater &Vent-Final 13.• Roof Drains 64.. Plumbing System• Final 14. Rough Plumbing • in, 65. Electrical-Final - 15. Rough Electrical-Conduit �! 66. Solar System-Final - 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign - - 68. APPROVED FOR PLASTERING 18. Rough Electrical:T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace '. 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping OGas ❑Oil 23. Gas Pipe-Rough & Test 72. Underground Flush - 24. Roof Framing 73. Undergrnd. Storage Tank ❑Gas ❑Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27: Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter-Final 4fi ' 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning , i 35. Final Gas Pipe-Test 36. Hood or Canopy " 37. Final Factory Fireplace . 38. Final Plumbing 39. Water Service-Final 40. Gas Service-Final 41. Solar Domestic-Final 42. Backflow Preventer' 43. Backflow Irrigation; _ 44. ,Landscape Irrigation System _. .45. Sound Attenuation 46. Handicap Regulations - 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed - 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 1 .• 51. CERTIFICATE OF OCCUPANCY No. Date