HomeMy WebLinkAbout1612 PRIMROSE ST - Building Permits CITY OF COSTA MESA
40" Fs
BUILDING DIVISION
}@ 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
a FOR INSPECTIONS CALL: (714)754-5626
•
PERMIT NUMBER: M11-00053
PERMIT TYPE MECH STATUS: ISSUED
APN: 13929101 DATE ISSUED: 04/06/2011
ISSUED BY: RMD
JOB ADDRESS: (-4.1.612'PRIMROSE-ST CM7—. Suite/Unit:
Vicinity: ATTIC ARE? '— - -
SQ. FT: 0
SCOPE OF WORK: MECHANICAL PERMIT TO REPLACE EXISTING DUCTING LOCATED AT ATTIC FOR A SFU. NO OTHER
WORK AUTHORIZED UDNER THIS PERMIT.
OWNER: BROCKERT, CAROLYN M TR Address: 1612 PRIMROSE ST Unit:
PHONE: 714-540.2894 City/State/Zip: COSTA MESA,CA
APPLICANT: DAVIDSON, LYN Address: Unit:
PHONE: 714-978-7877 City/State/zZip:
CONTRACTOR: AIRWEST AIR CONDITIONING AND HEATING INC. License No. 733715
Address: 1886 SANTA CRUZ STUnit: PHONE: 714-978-7877
City/State: ANAHEIM,CA ZipCode: 92805 CELL:
MECHANICAL PERMIT FEE SUMMARY
MECH ITEM FEE: $37.20 •
PLAN CHECK FEE: $0.00
INVESTIGATION FEE: $0.00
REINSPECTION FEE: $0.00
TOTAL FEES: $37.20
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§ 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE r. INSPECTION TYPE DATE umnxiS CODES IN$PECTIONTYPE DATE INI1111ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical X '9 "/C/—// tixV 4'
1266 Pool Spa Final _ 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall _ 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
WORKERS'COMPENSATION DECLARATION: Owner ID verified by drive.-,icense. 0 Yes 0 No
I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires:
O I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed):
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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a
number are: L person is required to descend,will be made in connection with work authorized
Ca 5?_ COM 1n 1 N 7� r,, by this permit,and that no building structure,scaffolding,falsework,or demolition
(ID's
seethe,need nota,xxnpl2eted ane averred at arta hundred dollars(Sr00)aMs2,Art 2,Sec.341,Ttle 8,California Administrative Code).
s) or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp
Policy Number:
H. "J 3 O
o As owner-builder, I will not employ anyone to do work which would
O I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should
become subject to the workers'compensation provisions of Section 3700 of Applicant's Signature Date
the Labor Code. ILII forthwith comply with these provisions.
`f'7(1)v j� �( N_/ ^) f Division of Industrial Safety Permit Number:
t/ `Ap n gnam3te t' HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES, 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
LICENSED CONTRACTORS DECLARATION: 500 pounds.or a volume of 55 gallons.or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code,and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? ❑Yes ❑No
C L _7 337 t CClass.# ,C+- azo (Section 25533 of the California Health and Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by
— 6 - (/ each business which at any one time has on hand a quantity of acutely
agony cess . GDate__ 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
El I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? ❑Yes ❑No
(Section 25534 of the Califomia Health and Safety Code provides that the
Lender's Address: 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.
Signature Date
4. If an RMPP is presently required. has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes ❑No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If yes".the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property. or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec. 7044, Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by Califomia
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? ❑Yes 0 No
(hereon,and who does such work himself or herself or through his or her own
8. (If yes",attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions.
LICENSED CONTRACTORS to construct the project(Sec.7044.Business and
Professions Code: The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that f have read this application and state that
❑ I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
Signature of Legal er(s) JDate
Signature Date - -. C/745 —1 /
3057.46(3107) qq�
rmoror Authorized A plant Date
tarsi rtfe CITY OF COSTA MESA
a-, •� BUILDING DIVISION PERMIT NUMBER
( •''r"' ' DEVELOPMENT SERVICES DEPARTMENT
4 PERMIT MOO-00094 -
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT •
Job Address: 1612 PRIMROSE ST Status: ISSUED
Suite No Applied: 03/08/2000
Issued: 03/08/2000
Vicinity: SIDE YARD
Parcel Number: 13929101
ISSUED BY:
Applicant: EMETT, JOSEPH
Address: 1180 N. FOUNTAIN WAY#F
Phone: (714)630-6330
ANAHEIM,CA Zip: 92806
Owner: BROCKERT, CAROLYN M TR
Address: 1612 PRIMROSE ST
Phone:
COSTA MESA,CA Zip: 92626
Contractor: HOME ENERGY SPECIALISTS INC.
Address: DBA: WEST COAST ENERGY
ANAHEIM,CA Phone: (714)630-6330
1180 N.FOUNTAIN WAY#F Zip: 92806
License: 685478
Arch I Eng:
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
CHANGEOUT EXISTING 80K BTU FORCED AIR UNIT&ADD NEW AIR CONDITIONING.
FEE SUMMARY
Quantity Quantity
ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0
Inst FAU<100 k BTU $14.80 1 Repair/Alt Refrigeration Unit $0.00 0
Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0
Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0
Inst/Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0
Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0
Ref rig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems
Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0
Factory Fireplace $0.00 0 3 To 15 hp/500 k BTU $0.00 0
Hood w/Mech Exhaust $0.00 0 15 To 30 hp/1,000 k BTU $0.00 0
VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00 0
Vent Fan/Single Duct $0.00 0 Over 50 hp/Over 1,750 BTU $0.00 0
Appliance $0.00 0 Boilers
Fire Dampers $0.00 0 Up to 3 hp $14.70 1
Smoke Dampers $0.00 0 3 To 15 hp $0.00 0
Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0
Air Handlers< 10000c-fm $0.00 0 30 to 50 hp $0.00 0
Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0
Floor Furnace $0.00 0 Other Mechanical Fee
Floor or Suspend Heater $0.00 0 Investigation Fee $0.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
DECLARATIONS •
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations: •
❑ 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
�`ork for which this permit Is issued.
g.,0 Cleve 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',,,co--777rrrRRRp,,ensatioyyn I�nsurance carrier and policy number are:
f Cartier --A , A., 1/i- aicyNumber: iC)/3-9/t4 7' Cten.47
-(Thisaecflon need not be completed If the permit Is valued at one hundred dollars($100)or less.)
❑ I certify that In the pe •mance 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 I .Hernia,and agree that if I should be,•me subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these prov
Appl cant Signature: / Date:
RNING7FNLLRE TO SECURE ORKERS'f'•• •TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMIL ER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(5100,000) IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE.INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that-i-em'' 'nsy. .�rr. ;lit • Chapter 9(commenting with Section 7000)of Division olfthe.Business and Pr sslons Code,and my license is in full
fezeandeflect.6c.` I TACH mit I ;Class a_ L--
tiactors Signature: !ran" r y - . •Date: 3 —5l5---r- Ci
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is issued.(Sec.3097,Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I em 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 toe 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.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. 0 Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit.end 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,Califomia Administrative Cale).
❑ 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? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any ono time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the Califomia Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
u ycomped __._..
4 If an RMPP is presently required,has Section 25534 of the Califomia Health and Safety Code been fully complied with? 0 Yes 0 No
....,-.Doe...or._will
bjecof-this pylic
5 Does e wo the tcAir orQualpresentity
aa future building occupant at requirer for the work which isi the subject f this a estlon a ermlt for such construction or modification
from the South Coast Air Quality Manegemenl District or from any other air pollution control district or agency? �Yes �No
(Section 65850.2 of the Califomia Govemment Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑Yes 0 No
8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct.I agree to comply with all state laws and city ordinances relating to building construction,end authorize representatives of the City of Costa Mesa to enter upon the
above-described prope for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
I�` i.nature•• g: Owne..i —
1 —/
'?d,1•r Authorize. ••plicant P.[Date ,�.rR/�
CODE
TY
CODE
INSP
CTION
7111
1616 r Fixed System Final Fire Prevention P9I€ 1E0814206 4 Final Mechanical C 4/9'PO F(// ,per
1266 Pool Spa Final 208 Final Plumbing ! (f
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
2446-46
a o� CITY OF COSTA MESA
a , BUILDING DIVISION PERMIT NUMBER
1-1 "T"' ' DEVELOPMENT SERVICES DEPARTMENT
4. PERMIT E00-00189
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626.
ELECTRICAL PERMIT
Job Address: 1612 PRIMROSE ST Status: ISSUED
Suite No Applied: 03/08/2000
Vicinity: SIDE YARD Issued: 03/08/2000
Parcel Nunmber: 13929101
Applicant: EMETT, JOSEPH ISSUED BY:
Address: 1180 N. FOUNTAIN WAY#F
Phone: (714)630-6330
ANAHEIM,CA Zip: 92806
Owner BROCKERT, CAROLYN M TR
Address 1612 PRIMROSE ST
•
Phone: •
COSTA MESA,CA Zip: 92626
Contractor: HOME ENERGY SPECIALISTS INC.
Address: DBA: WEST COAST ENERGY
ANAHEIM,CA Phone: (714)630-6330
1180 N.FOUNTAIN WAY#F Zip: 92806
License: 685478
SCOPE OF PERMIT
ELECTRICAL PERMIT FOR 3 HP MOTOR FOR INSTALLATION OF NEW AIR CONDITIONING.
REF:M00-00094
FEE SUMMARY '
Quantity Quantity
ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0
Temp service test $0.00 Busway/100 ft $0.00 0
Res.a/c package $0.00 Standing Section $0.00 0
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0
New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0
Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0
Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0
Switches $0.00 0 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 Wring System/Ckt $0.00 0
Service to 200a $0.00 0 Misc.Conduit $0.00 0
Service to 1000a $0.00 0 Misc.Conductor $0.00 0
Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0
Motors to lhp $0.00 0 Circus(mech ride or lights) $0.00 0
Motors to 10hp $12.30 1 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
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
• DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I rtereby affirm u rjof the following tledarations:
I h end will mpenaltyaintainof a pecertifuryicateone at consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
rk 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' omp nation 1�5wence abler and policy number are: - /
I'Carrier: .T J�2 f LA�6lJl� ,Polite Minter: 179'fl c-(r u7&eo- n
-(This-section need not be completed it the permit Is valued at one hundred dollars($700)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 California,and agree that if I should become subject to the workers'compensation provisions of Section 37 f the Labor Code,I shall forthwith
comply with these visions. � n,,/�
Applieam'Signeture: aga—
�Date: 3. > r(�-�J
EWABMNa.FAILURE TO SE URE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EM OYPL ER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(51 ,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm the ..,am.licensed der•rovis•n- • Chapter 9(commencing with Section 7000)of Division Rte Business and Profe 'onss Code,and my license is In full
farce end effect. c.a ^�+'-'
Contmctofs'Slgna ure: O'er . r �tate:
CONSTRUCTION LENDIN• 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 Ucense Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom end 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 properly,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions 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.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-properly tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person is required to descend.will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,faisework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title B.California Administrative Code).
❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the Califomia Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required.has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aggermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes Ll No
(Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 II a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described pr'perty for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
'.mat est eget Owner -,�
Imo_ ►6��-
to i'ruthomn5 pplicant-- P O ate
CODE r • A' INTRIALE CODE( INSPECTION TYPE ggTF INTITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1268 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical IWO?T AN yu
201 Final Bleck/Retaining Wall 212 Final Fire Prevention /l/I
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
2446-46
• a1 F 9 CITY OF COSTA MESA
BUILDING DIVISION
F - ,.,, ,i• DEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER
4. ' • PERMIT
""�'� 03-01132
(714)754-5273 • Fax(714)754.4856 • www.ci.costa-mesa.cuUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1612 PRIMROSE ST Status: ISSUED
Suite: Applied: 07/03/2003
Vicinity: FAMILY ROOM/BATH Issued: 08/11/2003
Parcel Number: 13929101 Zoning:
Applicant: SAM SEERY ISSUED BY:
Address:
Phone: 562-884-1280
Zip:
Owner: BROCKERT, CAROLYN M TR
Address 1612 PRIMROSE ST
Phone: 714-540-2894
COSTA MESA,CA Zip: 92626
Contractor: S J SEERY
Address: 203 ARGONNE
Phone: (562)884-1280
LONG BEACH,CA
Zip: 90803 License: 364290
Arch : Eng: DAVE ANDERSON
Address: Address: 24352 BERRENDO
Phone: SUITE 6 Phone: 949-643-8681
LAGUNA HILLS,CA
Zip: License: 92656 License:
SCOPE OF PERMIT
ADD 485 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:ADD A FAMILY ROOM AND BATHROOM.NO OTHER WORK TO BE COMPLETED.
CONVERT 3 BEDROOM,2 BATH S.F.D.TO 3 BEDROOM,3 BATH S.F.D.
•
59%OPEN SPACE
14%REAR YARD COVERAGE
FEE SUMMARY
Plan Check: $385.94 Calc Valuation: $44,814.00
Permit: $593.75 Claim Valuation: $0.00
SMIP Res: $4.48
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $984.17
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
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 it work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result In the expiration of this permit:"
FOR INSPECTIONS CALL: (714)754-5626 <
2446-46(6/00)
DECLARATIONS n
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.
❑ 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 Ls issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
\
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
�❑�
!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 o Ca fornia,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 pro 510 \ 0-3
AppllcanfSlgneture: % /Date)/
WARNING FAILURE TO SECUR ERS' SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOUARE($117,000), N ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby.affirm.that I am tic sed unr9gqr provisions of Ch@(/ter 9(commencing with Section 7000)of Division 3 of the Business and ProJeqsi Code,and my license is in full
'force andeflect..Lic_a ''} •6 '61 /) Cla_u_a. ✓{ i
C tors.Signature: /-_Date: Q" / 03
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,CMI 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 ts 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 end 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 end Professions Code:The Contractors License Law does not apply to an owner of properly who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a 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 driver's license. 0 Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet In depth into which a person is required to descend,will be made In connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Flre Depanment by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which ere required to register acutely hazardous materials with the Fire Department.
4 If an RMPP Is presently required,has Section 25534 of the California Health end Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application agermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? la Yes LI No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any pan of the facility to bo constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(It 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? 0 Yes 0 No
8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-descri d property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of Legal Owner(s) 3 Date
d/Or Authorized Applicant Date
CODE r INSPECTION TYPE • PATE INMI& CODE! •INSPECTIONTYPE ^ - • PAIL • PITJUA44
1816 Fixed System Final Fire Prevention 206 Final Mechanical •
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention _
202 Final Factory Firo Place 220 Final Planning Approval
203 Final Sign 222 Final Site �
204 Final Demolition 250 Final Buitding/Occupancy 740-04( 4"
•
,Q ' 6 9 CITY OF COSTA MESA ..
0
BUILDING DIVISION
• :r A. DEVELOPMENT SERVICES DEPARTMENT P RMIT NUMBER
�. PERMIT E03-00722
m le
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 1612 PRIMROSE ST Status: ISSUED
Suite No Applied: 08/11/2003
Vicinity: Issued: 08/11/2003
Parcel Nunmber: 13929101 /�]}
Applicant: S J SEERY ISSUED BY: .�/
Address: 203 ARGONNE
•
Phone: (562)884-1280
LONG BEACH,CA Zip: 90803
Owner: BROCKERT, CAROLYN M TR
Address 1612 PRIMROSE ST .
Phone: 714-540-2894
COSTA MESA,CA Zip: 92626
Contractor: S J SEERY
Address: 203 ARGONNE
Phone: (562)884-1280
LONG BEACH,CA Zip: 90803
License: 364290
SCOPE OF PERMIT
ADD 485 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:ADD A FAMILY ROOM AND BATHROOM.NO
OTHER WORK TO BE COMPLETED.
CONVERT 3 BEDROOM,2 BATH S.F.D.TO 3 BEDROOM,3 BATH S.F.D.REF.: B03-01132
•
ELECTRICAL TO INCLUDE: 15 LIGHT FIXTURES, 15 OUTLETS, 10 SWITCHES,AND 1 SERVICE TO
200 AMPS.
FEE SUMMARY
Quantity Quantity
ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0
Temp service test $0.00 Busway/100 ft $0.00 0
Res.a/c package $0.00 Standing Section $0.00 0
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0
New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0
Lighting Fixts $16.50 15 up to 50 kva/kw $0.00 0
Recept Outlets $16.50 15 up to 100 kva/kw $0.00 0
Switches $11.00 10 over 100 kva/kw $0.00 0
Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0
Service to 200a $30.50 1 Misc.Conduit $0.00 0
Service to 100oa $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
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)
i
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 perm
i�
FOR INSPECTIONS CALL: (714)754-5626
2448-46(WOO)
DECLARATIONS cm
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.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Cale,for tho performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed If the permit is valued at one hundred dollars(8100)or less.)
I certify that in the rf mance 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 law 1 alifomia,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 ions. ,L /tl O3
Applicant Signature: Date:
WARNING:FAILURE TO SE UR WORKERS ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TOG{• PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(5100,000),IN ADDMON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that 1 am II :n ed nde provisl• s•f Chapter 9(commencing with Section 7000)of Division 3 of the Buss 9d10 ssions Code,and my license is in full
•
force and effect.Lie.q a ,,a I Class ft
7-Ji I l/
Contractors Signature: Date: 0
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant fore 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.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: '
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person Ls 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,Califomla 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? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure). ___ _ __
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
___ .. .__. ._ __....___ �_ _ 7;ateri_l._._.
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
__ u ....._.__..._ Subject _____ ...._. __.... _..__i_.
5 Does he coo the ap stcA r iar n building o oat y other for toe wonk ontch di the t agency?this a estion a eermit for such construction or;Codification
from the South Coast Air Quality Management District or from any other air pollution control district or �Yes IJ No
(Section 65850.2 of the Califomla Govemment Code requires that the requested information be furnished on applications for non-residential building permits).
6 W III any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast 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? 0 Yes 0 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.
Signature Of Legal Owner(s) ,/i /)/! ° ate
And/Or Authorized Applicant `( Date
;ODE I SPECTIONTYPE ' MI vnmAL$ ' CODE# INSPECTION TYPF ME MAI
1618 Fixed System Final Fire Prevention 206 Final Mechanical •
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical • 7-4-051 RHi
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
011 Mac CITY OF COSTA MESA
BUILDING DIVISION
re-r:;...' :.� DEVELOPMENT SERVICES DEPARTMENT PERM NUMBER
PERMIT
J4NPPOR.cmo P03-00514
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 1612 PRIMROSE ST Status: ISSUED
Suite No Applied: 08/11/2003
Issued: 08/11/2003
Vicinity:
Parcel Nunmber: 13929101 ISSUED BY:
Applicant: S J SEERY
Address: 203 ARGONNE
Phone: (562)884-1280
LONG BEACH,CA Zip: 90803
Owner: BROCKERT, CAROLYN M TR
Address 1612 PRIMROSE ST
Phone: 714-540-2894
COSTA MESA,CA Zip: 92626
Contractor: S J SEERY
Address: 203 ARGONNE
Phone: (562)884-1280
LONG BEACH,CA Zip: 90803
License: 364290
Arch / Eng :
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
ADD 485 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:ADD A FAMILY ROOM AND BATHROOM. NO
OTHER WORK TO BE COMPLETED.
CONVERT 3 BEDROOM,2 BATH S.F.D.TO 3 BEDROOM,3 BATH S.F.D.REF.:B03-01132
PLUMBING TO INCLUDE: 1 BATHTUB, 1 WASH BASIN, 1 WATER CLOSET AND 1 WATER PIPING.
FEE SUMMARY
AMT QTY AMT QTY AMT QTY
ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $0.00 0
Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0
Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0
Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0
Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0
Connect(Ice,Soda,etc) $0.00 0 Receptors . $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0
Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0
Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0
Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0
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 j
fora 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 (J
2446-46 WOO)
DECLARATIONS (Th
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.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit Is valued at one hundred dollars($100)or less.)
O I certify that in the erfo ance 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 law 1 C fomia,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 r vi s. // C—3
Applicant Signature: ' Date:
WARNING:FAILURE TO SEC RE W E SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLIARE($100, ),IN ADDITION TO COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTQRS DECLARATION:
I hereby affirm that I am licensetl d_r provisions ofhapter 9(commencing with Section 7000)of Division 3 of the BusIars qp 11 Pjessions Code,and my license is In full
force and effect.Lic.k s n Class A J ( �V!
Contractor's Signature: "fir Date:
CONSTRUCTION LENDING AGENCY:
9 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 Ucense Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business end 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 penally 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 Ucense Law does not apply to an owner of properly who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
O I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a
permit to do such work from the division.
Signature: _ _ Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes 0 No
(Section 25533 of the Califomia Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification
from the South Coast Air(Duality Management District or Irom any other air pollution control district or agency? LJ Yes Li No
(Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If'yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Duality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes -0 No
8 (If yes',attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
•
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of Legal Owner(s)-1\\.
/lam / zo 3 Date
k DC7( II / C
�y�ntllOr Authorized Applicant Date
000E A INSPECTION TYPE flAIE INTMAL4 CODE 1 'INSPECTION TYPE RAIL INTRIAL9
1616 Fixed System Final Fire Prevention ' 206 Final Mechanical •
p
1266 Pool Spa Final 208 Final Plumbing I"O -07 t3 .
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy `
p MF CITY OF COSTA MESA
4 BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER
F tPlika
. PERMIT '
M03-00394
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT
Job Address: 1612 PRIMROSE ST Status: ISSUED
Suite No Applied: 08/11/2003
Issued: 08/11/2003
Vicinity:
Parcel Number 13929101 ISSUED BY:
Applicant: S J SEERY
Address: 203 ARGONNE
Phone: (562)884-1280
LONG BEACH,CA Zip: 90803
Owner BROCKERT, CAROLYN M TR
Address: 1612 PRIMROSE ST
Phone: 714-540-2894
COSTA MESA,CA Zip: 92626
Contractor: S J SEERY
Address: 203 ARGONNE
Phone: (562)884-1280
LONG BEACH,CA Zip: 90803
License:364290
SCOPE OF PERMIT
ADD 485 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:ADD A FAMILY ROOM AND
BATHROOM.NO OTHER WORK TO BE COMPLETED.
CONVERT 3 BEDROOM,2.BATH S.F.D.TO 3 BEDROOM, 3 BATH S.F.D.REF.:B03-01132
MECHANICAL TO INCLUDE: 1 VENT FAN/SINGLE DUCT.
FEE SUMMARY
Quantity Quantity
ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0
Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0
Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0
Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0
Inst/Rep.Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0
Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0
Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems
Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0
Factory Fireplace $0.00 0 3 To 15 hp/500 k BTU $0.00 0
Hood w/Mech Exhaust $0.00 0 , 15 To 30 hp/1,000 k BTU $0.00 0
VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00 0
Vent Fan/Single Duct $7.25 1 Over 50 hp/Over 1,750 BTU $0.00 0
Appliance '$0.00 0 • Boilers
Fire Dampers $0.00 0 • Up to 3 hp $0.00 0
Smoke Dampers $0.00 0 3 To 15 hp $0.00 0
Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0
Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0
Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0
Floor Furnace $0.00 0 Other Mechanical Fee
Floor or Suspend Heater $0.00 0 Investigation Fee $0.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92.28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all i
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. /Jr
FOR INSPECTIONS CALL: (714)754-5626
244648(61%) 1_1
DECLARATIONS t I r�
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. -
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed It the permit is valued at one hundred dollars($100)or less.)
92 I certify that in t ,p••ormance 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 la . • alifornia,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‘.‘o 'ons. q
Applicant Signature:- r Date: (T� I 3D
WARNING:FAILURE TO SECU'E v-KERS't,"1 :ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(5100,000),IN ADDITION T• E COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby.affirm.that I am lice r and rovisioes 91 Chapter 9(commencing with Section 7000)of Division 3 of.the Busine d Prof essionql
Code,and my license Is in full
force and effect.Lic.# 1 �'i (/ (Class#_ r
--Contractors Signature: —�� [—Date: •
__---
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,CMI Code).
Lender's Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or Improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-properly tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature end pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the Califomla Health and Safety Code,with soma exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this implication akPermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? IYes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coacar Air(Duality 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 Califomla Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If yes',attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signa a Of Legal Owner(s) SVC J1 O� Date
(Andh"Authorized Applicant V I6 ( Date—
CODE I 'INSPECTION TYPE , ' QM f{TIALS 900E( WSPECTION TYPE - DATE MALS
1616 Fixed System Final Fire Prevention •206 Final Mechanical a-1?- a 1 . Q LV
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
. ,
c • '1
9 CITY OF COSTA MESA
4 BUILDING DIVISION
. •j __ , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
b. i�• in /
PERMIT /E02-00184
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 1612 PRIMROSE ST Status: ISSUED
Suite No Applied: 03/08/2002
Vicinity: KITCHEN Issued: 03/08/2002
Parcel Nunmber: 13929101 i
Applicant: BROCKERT, CAROLYN M TR ISSUED BY: 7
Address: 1612 PRIMROSE ST - -
., Phone: 714-540-2894 ,
COSTA MESA,CA Zip: 92626
Owner: BROCKERT, CAROLYN M TR
Address 1612 PRIMROSE ST "
Phone:
• COSTA MESA,CA Zip: 92626
•
Contractor: OWNER-BUILDER
•
Address:
Phone:
Zip:
License: 0
SCOPE OF PERMIT
ELEC PERMIT FOR INTERIOR KITCHEN REMODEL OF AN EXISTING SFD: 13 LIGHTS, 16 OUTLETS,
7 SWITCHES, 1 MISC EQUIP(MOVE/INSTALL 3/0), 1 CONDUCTOR.
FEE SUMMARY "
Quantity . - - Quantity
ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 '
Temp service test $0.00 Busway/100 ft $0.00 0
Res.a/c package $0.00 Standing Section " $0.00 0
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $18.20 1
New Res(3+units) $0.00 0 • Transformers up to 1 kva/kw $0.00 0 ,
Pool/Spa $0.00 0 • up to 10 kva/kw $0.00 0
Lighting Fixts $14.30 13 up to50 kva/kw $0.00 0
Recept Outlets $17.60 . _16 , " up to 100 kva/kw.- $0.00 0•
Switches $7.70: 7 over 100 kva/kw $0.00 0
Non Res Appl ' $0.00 0 Low Voltage Equipment $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt , $0.00 . 0
Service to 200a $0.00 0 Misc.Conduit $0.00 0
Service to 1000a $0.00 0 Misc.Conductor $18.20 1
Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0
Motors to 1hp $0.00 0 ' Circus(mech ride or lights) $0.00 0
Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 , 0 •
Motors to 50hp $0.00 0 Fireworks Stand $0.00 0
Motors to 100hp $0.00 0 Other Electrical Fee $0.00
Motors over 100hp $0.00 " 0 .
Communication drops $0.00 0 Investigation Fee ' $0.00
Sub panel to 200a $0.00 0 ' Plan Check Fee $0.00
Pole Light Pkg $0.00 0 Reinspection Fee $0.00
Sign Circuits $0.00 0
Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $99.50
Intermed Pole $0.00 0
COMMENTS/SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No,92-28,§1,12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-48 WOO)
DECLARATIONS c ' v
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.
❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE IVIDDOCO),IN ADDITION TOTHE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,IN I EHEST,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 It
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
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.If,however,the building or improvement is
ls Id 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.).
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 exemptAnder sec. Business and Professions Code for this reason:
Signature: -re 9� Date: — f'— O2_
Owner ID verified by drivers lic se. ❑Yes 0 No Drivers License No. Expires: 7-?(-03
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑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? 0 Yes 0 No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for ins ction py oses.I�occupy or allow occupancy of any building authorized by this permit until final Inspection.
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE# INSPECTION TYPE PAL 1[I$19L6 CODE INSPECTIONTYPE PATE =ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing n c_
200 Final Re-Root 210 Final Electrical �•M'J
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
`p CITY OF COSTA MESA
4 BUILDING DIVISION
• , ,,,..' : ,, DEVELOPMENT SERVICES DEPARTMENT PER NUMBER
l• I w•wwa'
4• PERMIT
Sb•Pa.WWW.4' P02-00134
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT _
Job Address: 1612 PRIMROSE ST Status: ISSUED
Suite No Applied: 03/08/2002
Issued: 03/08/2002
Vicinity: KITCHEN
Parcel Nunmber: 13929101 ISSUED BY: v .�
-061
Applicant: BROCKERT, CAROLYN M TR • .
Address: 1612 PRIMROSE ST
Phone: 714-540-2894 - -
COSTA MESA,CA, • Zip: 92626 ,
Owner: BROCKERT, CAROLYN M TR / .
Address 1612 PRIMROSE ST -
Phone:
COSTA MESA,CA Zip: 92626 ,
Contractor: OWNER-BUILDER . •
Address: ' - - _ -
Phone: '
. Zip: ,
License: 0
Arch / Eng:
Address:
Phone:
. - Zip: ,
License: - - -
. SCOPE OF PERMIT •
PLUMBING PERMIT TO RELOCATE KITCHEN SINK FOR AN INTERIOR KITCHEN REMODEL OF AN
EXISTING SFD. 1 KITCHEN SINK
NO OTHER PLUMBING WORK WITH THIS PERMIT.
•
FEE SUMMARY - . . /
AMT OTY, - AMT QTY • - - " /AMT QTY
ISSUE FEE . $23:50 Laundry Tub/Washer $0.00 0 " Sump Pump $0.00 0
Backflow irrigation ' , ' $0.00 0, , _ A Landscape Irrigation $0.00 0 . - Swimming Pool ,,i' ' $0.00 0
Backflow Preventer $0.00 0 - P-Trap $0.00 0 - Trap Primer " $0.00 0
Bathtub $0.00 , 0 Pressure Regulator $0.00 0 Urinal - $0.00 0
Clarifier System $0.00 0 - Process Piping(per 10 ft) $0.00 0 ' Vacuum Brkr Bkflow(1-4) $0.00 0
Connect(Ice,Soda,etc) $0.00 0 _ • Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0
Dental Units $0.00 0 - Septic Tank $0.00 0 - Wash Basin $0.00 0
Dishwasher $0.00 - 0 Sewer Cap for Demo $0.00 0 ' Wash Basin Set $0.00 0
Drain, Floor $0.00 0 - Sewer Connect $0.00 0 / Waste and Vent System $0.00 0
Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0
Drain,Roof $0.00 0 Shower . $0.00 0 Water Heater I vent $0.00 0
Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0
Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0
Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0
Gas(1-4 outlets) $0.00 0 Sink,kitchen $9.80 1 Water Softener $0.00 0
Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00
Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00
Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00
Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0
Interceptors(Sand Auto) $0.00 0
TOTAL CALCULATED FEES: $33.30
COW/MIN t S r SrCCIAL CONDI r[Cola"-
NOTICE:
OwrNOTICE: 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
244648(WOO)
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.
❑ 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'compen§ation Insurance carrier and policy number are:
Carrier: I Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Califomia,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.# Class#
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
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 properly who builds or improves thereon,end 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
�
Id 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.).
fd' 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: `Cpet,t.4 9]�J Date: ?.-7' O? ,
Owner ID verified by drivers lic6hse. ❑Yes 0 No Driver's License No. Expires: 7-2/—Q.-
Verification
-a/-2Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,Califomia 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 W III the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes 0 N
(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 Califomia Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LI Yes S No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to he constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Cuality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No
8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described pro rty for inspection purposes. gree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signa Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE 0 INSPECTION TYPE DATE INTITUL$ CODE I INSPECTION TYPE OAIE INITOELE
1616 Fixed System Final Fire Prevention 206 Final Mechanical .(1 w
1266 Pool Spa Final 208 Final Plumbing . s-I S- 2. 131"!
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
si M CITY OF COSTA MESA
4
BUILDING DIVISION •
0. �� �' DEVELOPMENT SERVICES DEPARTMENT P IT NUMBER
t.oa 4• eER' �`T
B02-00327
(714)754-5273 • Fax(714)754-4656 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
—
Job Address: 1612 PRIMROSE ST Status: ISSUED
Suite: Applied: 03/08/2002
Vicinity: KITCHEN Issued: 03/11/2002
Parcel Number: 13929101 Zoning:
Applicant: BROCKERT, CAROLYN M TR ISSUED BY: A
Address: 1612 PRIMROSE ST " - - -
;�- '' - :Phdne: 794-540-2894
COSTA MESA CA ' Zip: 92626
Owner BROCKERT,'CAROLYN MTR, - �
Address 1612PRIMROSE ST —
' - - Phone:
COSTA MESA,CA ;- ` Zip: 92626 - /
Contractor: OWNER-BUILDER , ' ' '
Address:
Phone:.' .
Licenser' 0 -
Arch : . , „- Eng: - . .
Address: Address: ,
�- Phone:
l
\: Zip: 'License: License:
.SCOPE OF PERMIT
INTERIOR KITCHEN REMODEL O_F„AN EXISTING SFD.WORK TO INCLUDE CHANGE=OUT OF A KITCHEN WINDOW, '
ELECTRICAL AND PLUMBING. - '
FEE SUMMARY . '
Plan Check: $21.22 = - - - -- - ' . - , - Calc Valuation: $600.00
Permit: $32.65 ''' / Claim Valuation: $eoo:oo
SMIP Res: . $0.50
SMIP Corn: $0.00
Other: $0.00 '
Inspection: $0.00
Total: • $54.17 ,'
. 'K 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 / i
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 -
•
2446-46(6/00)
DECLARATIONS •
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
O I have and wilt maintain workers'compensation insurance,as required by sectierl3700 If the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are: a
Carrier: Policy Number:
is section need not be completed if the permit is valued at one hundred dollars($100)or less.)
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 Sectio 3700 of the Labor Code,I shall forthwith
comply with these provisions. n
Applicant Signature: (i.(i.r--aid d � �. Date: 3 h13 �
WARNING:FAILURE TO SECURE WORKERS' NSATI N COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIE AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR COOE,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
fo I atuc.tl Dates: b
r' art t �i Date:
•
CONSTRUCTION LENDING AGENCY:
O 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
hiself 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
r, bId 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.).
L//M�t`/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 exe/0�/pt�under s . A. / t.siness and Professions Code for this reason: I
Signature: l� 7n,V. Date: 3(i t 0a-
,
Owner ID verified by driver'' 'cense. I• es 0 No Driver's License No. Expires:
Verification of Ownership by(type of do ent,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,Califomia Administrative Code).
O 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? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,ore volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature end 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 0 No
(Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? IL.1 Yes No
(Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No
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 iDspectio>pumes.I agree not to cupy or alloy occupancy of any building authorized by t4is p rm' until final inspection.
_
Signature Of Leg Owner(s) (/ Date
C A If�/�(ittlefli Date
CODE 11 INSPECTION TYPEPAIL tHTITIAL5 CODE! INSPECTION TYPE PAIS MALE
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place - 220 Final Planning Approval •
/)
203 Final Sign 222 Final Site �,L
204 Final Demolition 250 . .Final Building/Occupancy ®z (,7/,f�/,/L-
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PROJECT ADDRESS: 1612 PRIMROSE ST UNIT: CITY OF COSTA MESA - BUILDING PERMIT PERM NO: BE 052372
OWNER'S NAME: BROCKERT, CHARLES M
ADDRESS: 1612 PRIMROSE ST PERMIT NO: BE 052372 PLAN CHECK NO: 02038-91 S GOVT: N SUPP: N
COSTA MESA,CA 92626
CONSTRUCTION TYPE: PERMIT TYPE: ELE STR PURPOSE: ADD
o ARCN/ENGINEER: 540-2894
REG.NO.: -
ADDRESS: UNIT: JOB DESCRIPTION : 336SF PATIO COVER SQ FT: 336
mr PERMITTEE: CLAIM VALUE: 4, 000. 00 CALC-VALUE: 4, 636. 80 GROUP OCC: R-3 /
ADDRESS: C.M. BROCKERT ( 714 ) 540-2894
1612 PRIROSE COMMENTS: ELECT FOR ABOVE GROUND SPA •
� p
C.M. CA 92626 ******�ETiiE�F ***—*>E *****� �F*�E;E>E �L****>E�Ex>F>F>E>Fal**** FREIE***>EDLx -K—•xyq 5��
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section ZONING R E Q U I R E M E N L.. LJ Crre&t
7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. SETBACKS
CITY LIC.: STATE LIC.: CLASS: I( J�`�($ED
Date: Signature: MAIN BUILDING -- ACCESSORY lS1:r ING ---
WORKERS'COMPENSATION DECLARATION: I hereby af firm that I have a certificate of consent to self-insure or a certificate of Workers' FRNT: 20 FT IN REAR: 18 FT IN FRNT: FT IN REAR: FT IN
Compensation Insurance,or a certified copy thereof(Section 3800, Lab.CI. LEFT: 18 FT IN RGHT: 18 FT IN LEFT: FT IN RGHT: FT IN
POLICY NO.: EXP.DATE:
COMPANY: PARKING REQ: PROV: PARCEL : 13929101 ZNE: R1 REF NO:
r -1 Certified copy is hereby furnished. 0 Certified copy is filed with the city Building Division. PLANNING NOTES> 336 SQ. FT. PATIO COVER ON AN EXISTING RES.
> •
date: Applicant: 3E*********3F***********IE*******************************************.*******3f*****
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permit is ler one hundred($100)or less). DEVELOPMENT SERVICES REQUIREMENTS
I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become
subject to me Workers'Compensation Laws of California. ZONING APPROVED BY CC DATE: gyp- I( ( \
Date: Signature:
NOTICE:If.after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY : DATE: •
Code.you must forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED B Y: I* ** * DATE-
which � j�
this permit is issued(Section 3097,Civ.C). ******** ************ ** ** -- - ... w.
. - - - , •.. •r* 49
if.)9 Fe ;rx -R1**.
LENDER: *********************************Ii*************lf***************ii***************
ADDRESS: LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit 10 construct,alter,improve,demolish,or PERMIT 72 . 00 1 1 00 • 50
repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed
pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business 0$ SMIP/ . 50
repair
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN 46 . 80 '
any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars($500). ISSUE FEE 15 . 00
I. as owner of the property or my employees with wages as their sole compensation,'wit do the work, and the BUILDING-DIV—> PERMIT ISSUE _ PLAN—CHECK TOTAL PAID DUE
wi structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law TOTALS----> 83 . 50 15. 00 - 46 . 80 145 . 30 - 145. 30 ' - . 00
does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through
his her ownisemployees.provided that pimprovements nle are not intended bd de of lir shIf,however d building or REVENUE DIVISION TC)TALS--> COLLECTED: 145. 30 OVER/SHORT: . 00
hisimprovementor soldmwithins.one year completion,suhlmp ove entsr will have the burden ft proving he/shele. did not buildthor improver
, for the purpose ol sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK
I,as owner of the properly.am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 72 . 00 26 . 00 . 50 ' '` 46 . 80
❑ and Professions Code: The Contractors'Slate License Law does not pply to an owner of property who builds or improves thereon I
and who contracts tor such projects with acsntractor(s)license ursuant to the Contractors'State License Law). l am aware *.*.*.*****.*.*.*****.X..****************lE************'*X*********dF********JE*********if***
that proof o1 their Worker's Compensation insurance should b mvided to me. INDIVIDUAL F E E BREAKDOWN
❑ e
a
I m exempt under Section: B.8 P.C
• for this exempt
TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST
Date: Ce ( lV ( C Dwne. 2P -�-
I do hereby certify that am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and SFR 336 RES—PATIO COVER—POST & SOLID ROOF 13 . 80 4, 6 3 6 , 8 0
ELE 1 MISC APPARATUS NOT LISTED REQ PERMIT 1.1 . 00 11 . 00
25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a
permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt from END OF FEES .
thee:provisions. Y
Date: Applicant:- /
I hereby certify that I have read this application a state that the above information is correct I agree to comply with all city and county
ordinances and state laws relating to building co ruction and hereby a prize represent at Ives oft Ily lm enter upon the a ve-mention -
property far inspection purposes. .1 �,.. -
/�� q l O u 23089?—DP3E� 6 : o': `_ r;.,'
Date: (0" //— !/ Signature:• l ./Le21-j[` )1,1 • - lila: 06/ .11791. T1.itE: i-r.40; 1
Driver's License or Social Security x:
1641.46 White-Building:Green-Code Enforcement:Canary-Applicant:Pink-Revenue;Goldenrod-Assessor
CONST.RUCTI8N AND PLANNING - POOL PA
APPROVALS Permit# Date Inspector 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 56. Rough•Plumbing & Pressure Test
6. Electrical UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings a-/3-?f ac.'// 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 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
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts, in Structure 70. Underground Hydro
22. Ducts,Ventilating •
71:Product Piping 0 Gas 000
•
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat • 75. Dry Chemical
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 R,let,EN2tes.
34. Final Heating & Air Conditioning �/ -
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 ¶fr5 9/ 6ft4/14- - .> o-._ Cc-at
48. FINAL PLANNING
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co •
' •
51. CERTIFICATE OF OCCUPANCY •
•
r
r
No Date
PROJECT ADDRESS:NAME: 1612 PRIMROSE ST UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 05317E
OWNER'S NAME: BROCKERT, CHARLES M -
I �. Anp@Ess: 1612 PRIMROSE ST PERMIT NO: B 053175 PLAN CHECK NO: 02847-91 S GOVT: N St7PP: N
' COSTA MESA, CA 92626
• CONSSTRUCTION TYPE: 5—N PERMIT TYPE: STR PURPOSE: OTH
AflCH1ENRESS: REG.NO.:
ADDRESS: UNIT: : SQ
JOB DESCRIPTION 65LIN FT OF RCMU WALL 0 6 ' HIGH FT: 65
PERMITTEE: CLAIM VALUE: CALC—VALUE: 1, 300 . 00 GROUP OCC; R-3 /
CAROLYN BROCKERT ( 714 ) 540-2894
ADDRESS: 1612 PRIMROSE ST COMMENTS : SMOKE DETECTOR(S) REQUIRED IN HOME.
COSTA MESA CA 92626 #3(x.* E********** ************** *+C***>E?F*at*****+E*aru********** �)qy tisitict
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z O N I N G R E Q U I R E M E N T S �• ®�
71X0)of Division 3 of the Business and Professions Cone,and my license is in full force and effect. S E T B A C K S ^
CITY LIC.: STATE LIC.: CLASS: p t IRED
Date: Signature: MAIN BUILDING ACCESSORY BUI D IaVAL• C
•WORXERS'COMPENSATION DECLARATION: I hereby affirm that I haves certificate of consent to self-insure or a certificate of Workers' FRNT: FT IN REAR: FT IN FRNT; FT IN REAR: FT IN
Compensation Insurance.or a certified copy thereof(Section MOO.Lab.Cf. LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
POLICY NO.: EXP.DATE:
COMPANY: PARKING REQ: PROV: PARCEL : 13929101 ZNE: R1 REF NO:
i §:"d Certified copy is hereby furnished. ID Certified Copy is filed with the city Building Division. PLANNING NOTES> 65 L,FT, BLOCK WALL 6 FT. HIGH ALONG REAR PROP. LINE
rt,. > NEED PARTY WALL AGREEMENT.
tiate: Applicant: ****,********************#***********IE*********************************x*********
c
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred($1q)or less). DEVELOPMENT SERVICES R E Q U I R E M E N, TT• S
I certify that in the performance of the work for which this permit is issued,I shaft not employ any person in any manner so as to become
subject to the Workers'Compensation Laws of California. ZONING APPROVED BY �a
. �S'�l' DATE: _z�3/�9/
Date: Signature: —
Code, :II,after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY : i i if/� _ DATE: ,5. f/
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 APPLICATION ISSUED B Y: DATE• 8 ll
which this permit is issued(Semon 3097,Civ.C). 'l— ste-,A�� . `e'"aK
LENDER: ***********************:?'x*********** *Fe* y'*************************************
ADDRESS: LEGALIZ,,ATION:N F E E SUMMARY STRUCTURAL SEGMENT: Y
OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RESP' GRADING
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 31 . 00 5.0
repair any structure.prior to its issuance.also requires the applicant for such permit to file a signed statement that he/she is licensed SMTP/NON-RES
pursuant to the provisions of the Contractors'State 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 PLAN 20 . 15
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500). ISSUE FEE -
I, as owner of,the property or my employes with wages as their sole compensation, will do the work, and the BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID . DUE
❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law TOTAL S----> 31 . 5 0 0 . 00 2 0. 15 51 . 65 51 . 65-,-. 7. . 00
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 q
improvement is sold within one year of completion,the owner will have the burden of proving he/she did not build or improve REVENUE DIVISION TOTALS——> COLLECTED;; 51 . 6 5 OVER/SHORT: 00
for the purpose of sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING *PLAN—CHECK
r n I,as owner of the property,am exclusively convecting with licensed contractors to construct the project(Section 7044,Business 31 •0 U , 5 0 20 . 15
,4 and Professions Code: The Contractors'State License Law does not apply to an owner of properly who builds or improves thereon • ' ^
and who contracts for such projects with a contractor(s)license pursuant to theContractors'Stale License Law). l am aware .)(..x.*.)f.*..***.T(.*.**.**.*.**.**.jl.**{(.**.*.*************************.*****.*x.*.*********)f{h********•-JL.
that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN
❑ ' I am exempt under Section: B.&P.C.
for this re son: /J TYPE QTY DESCRIPTIO N UNIT COST _TOTAL COST
Date: �'� //9` owner: SFR 65 RES CONCRETE BLOCK WALL / FT. 20 . 00 1 , 300 , 00
I do hereby arty that I am aware of and understand the requirements of California Health an Safety Code Sections 25505,25533,and END OF .FEES 7 /
25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a fV/
permit for construction or modification from the Air Duality Management District.Residential construction applications are exempt from
'these provisions/
/,'
Dale 4_�/ � Applicant: / _ —_.may. . _. Al a _ r• y
I hereby certify that I have read this application and state that the above inform ion is correct.I agree to comply with all city and,county - _
ordinances and slate laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned 111 c'G2y'..Cf__'cc 6.5! 7:D 2 ;,,,,,
property for inspection purposes.
Date: 7/IJ/ Signature:=[Gzry l — D_J'_ q✓)10,"letiC-
' .. -
Driver's License or Social Security#:
1641-46 White—Building:Green—Code Enforcement:Canary—Applicant:Pink—Revenue;Goldenrod—Assessor
ci.;-' POO PA
CONSTRUCTION AND PLANNING N -
9>,PPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector
1. remporar Electrical Service or Pole ''�'
E Y 52. Pool & Equipment Location < -
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement r „ /
3. Electrical Conduit Utility-Undrgrnd. 54. Forms ./� .'J- /
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. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation • 59. Gas Pipe, 0 Undrgrnd.,Test `,A
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, 0 Undrgrnd, �'
10. Structural Floor System - 61. APPROVAL TO DECK -• 4
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 '. Q 7
15. Rough Electrical-Conduit 66. Solar System-Final ; .A r
16. Rough Electric Wiring • 67. Fencing & Access Approval %', ,r i
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING r 1
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning - FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace - . APPROVALS Permit #
21. Ducts, in Structure 70. Underground'Hydro • '
22. Ducts, Ventilating - 71. Product Piping 0 Gas ❑Oil
23. Gas Pipe-Rough & Test 72. Underground Flush.
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil '
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat . 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding _ • 77. FIXED SYSTEM FINAL
29. Insulation (V U,' ';;r 78. FIRE PR EV. FINAL
30. Drywall Nailing - in; %1i HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat• i ^._yA. 79. •FINAL INSPECTION -
a
32. Electrical Power Meter-Final ..,:11447/5 80. FOOD CERTIFICATE ISSUED
'%I.._
33. Final Electric • • 1/•: -I Notes:
34. Final Heating& Air Conditioning i "'I, }/ -
c, O
35. Final Gas Pipe-Test • ' /7,-/A/- -
36. Hood or Canopy8 ' .
J
r
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 Pi?' PS
Sic Plf
48. FINAL PLANNING 'Z j is" ""^ (,�'y Cly/O
49. Electric Release to Edison .
:,/ .
50. Gas Release to Southern California Gas Co 2 7, ">I
•
51. CERTIFICATE OF OCCUPANCY
No. Date
•
PARTY WALL AGREEMENT
Qu�RED �"
\J \
4RT'S'.A.GREEMENT, made and entered into this/ 441,-/c day of
�/C�119t(�//99i we
and beten (�,/�IL�O. /L.hn n'1 /gear 4QJ
hereinafter referred to as 'LAND %NEV. and V/I /Y), /dce d Nan o4,-
hereinafter referred to as 'ADJACENT PROPERTY OkNER'.
It is hereby agreed that a party wall will be constructed on the
property line between /6/,/ i.Y,H o Se) a n
(Address of Adjoining Properties)
Hi/3. toAr t Cal
in the City of Costa Mesa, County of Orange, State of California, as per
map recorded in Book , Page of Miscellaneous Maps, in the office
of the County Recorder of said County. Me party wall shall be permitted to
encroach
IN WITNESS fEMH]P, the parties have entered into this Agreement the
day and year first above written.
LAND OhNER ADJACENT PROPERTY ChNER
tslgnat (Signature
C n e• Na &eo : 1 dre a.� c I E—
me ( or Printed) Nae (Typed or Printed)
/6/.2, ti , .„, os r`i c)1 i ' Whin/ft in/f-� C mJc-
(Address) kms?a /net a� CdM{t1-1 &r&. C-a- C`"'
1-4
926a26
will
Applicant to till in all spaces except those within heavy border lines and sign all appropriate declarations. -
CITY OF COSTA MESA - - -• p sE tA41T NO. n/ / TRACT NO. LQT NC],t BLDG.N0. - - 15:.6 I 2/11:/".-•
I 1'
tQP'i3S'kUCTIO/N PERMIT • L 6 p2 / S(d LI REPAIR
Address 16 - • r • C ` TYPE OF CONSTRUCTION U NEW ADD U ALTERATION REPAIR
Applicant's Mailing Address •SA!AIP ❑ CONVERSION 0 DEMOLISH ❑ OTHER
��(((��,,, �� A.P.# / .3q - � Zone R
(joiner's Name C r Al - /3ROL/Cd-A r Phone.0 DESCRIPTION OF WORK _Rj�M AOQ TSO/y S r I ` --
Address
Main Building: Accessory Building: 2
Address lH/2 P73/7YROSe' /.v• r r /� ' - E ' •
_ O
TYPE OF PERMIT GRADING r� FOUNDATIrO NN L STRUCTURAL T Front O N
A
Arch/Eng. - License No. ❑ TENANT L'J ELECTRICAL U PLUMBING L'J MECHANICAL Bear ,-- 1
Address 4 ❑ OTHER 2 3� 'J^� C Right
'� / _ G
//�� /t •'7 .--tom / /� ... N
Contractor's Name L I�A.1e Phone PROJECT DESCRIPTION SQ. F7 r �- OCCUPANCC t_^_ S �/ r 7 / ' E
CONSTRUCTION TYPE y- VALUATION S?� Left
Address(mailing) r-k_
ZONE GRADING CU.YDS. ACRES_ ,O00�^Ping Ref. • ' Park.Fees S. ,� ' Q
City-License No. • �y�I[// �s C• _ / U
LICENSED CONTRACTOR DECLARATION • Remarks: 1160 ia' PCH' �1G Pn ��% Parking Req./Provided •
I hereby affirm that I am-licensed under provisions of Charter.9(commencing 6 r R
with section 7000 of Division 3 of the Business and Professions Code,and P9 Use of Building: S1 z�yv� e, (A )recII[A 0 t-1CQ� - E
my license is in full force and'effect. • ��' /3 / _�� ,` I'�), � /
License Class • License No.• - PLUMBING \ FEES Planning-ni� Notes: /1/Q�./ - ,IJ.5' 7C(t,77'6AJ- , /.S E
Date Signature Bar Sink Showers a 7-t) {aS (J5ej J }-s. J f vl C/�// N
WORKERS'COMPENSATION DECLARATION - ! T7' L� _fly- T
•
ereby affirm that I have a certificate of consent to self-Insure or a certificate Backflow Preventer Service Sink f IG'U utse. e�s_M- 1C}t ONC re ' • S
Workers' Compensation Insurance, or a certified copy thereof (Section _ -
3800, Lab. C.);--� Ba• ckflow Irrigation 'Sewer Cap _ - - ' I ; ELECTRICAL FEES '
Policy No. Company ._ -77
8 Certified copy is hereby furnished: - , ' Btthtubs . • Sewer,Connection • _ % Automatic Washer)- Transformer 0 15-50:KW
Certified copy is filed with the city Building Division. - ❑ 50+kw
Date Applicant Clarifiers SolarCollectors- - ;),'- .. Construction Pole Sub. - •
_EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Dishwasher - ' ' Solar Piping •
Cooking Uni[ Meter ❑up to 100 amps.
(This section need not be completed if the permit is for one hundred ($100)or
II certify that iu.the performance of the work for which this permit is'issued,-I, Drinking Fountains Solar Tank • �. p Dishwasher , 'Meter Dpver 100 amps •
shall not employ any person in any manner'so'as to become subje t to the • - -• -
Worker Co4Qi�pensattion Laws of Caliior,e•- if• Floor Drains: Swimming Pool;w/Spa P•I Dryers ❑Gas, ❑Electric Sub Panel '
•
• Date . S c'•••••,' S Signature•' •#'t'. . d'I I e. i O -- -' r-
NOTICE: if,after making this declaration, you should become subject to the . Floor Sinks • Urinal . - Fan' I Motors❑0.1 HP ❑1'h-8 •
Workers' Compensation provisions-of the Labor Code, you must forthwith - . - ,
:comply with such provisions or this permit shall be"deemed revoked. Gas Service ; Outlets Water Closet
CONSTRUCTION LENDING. AGENCY, ' - F.A.U. Inc.Solar 09-15 HP 01'6-15++
I hereby affirm that there is a construction lending agency for the performance Interceptors. - ' Water Heater Z Fixtures :Microwave 0 40
of the work for which- t s permit -is issued (Section 3097 Civ. C.) - '
• Lender's Name /17o4/e ' - i _ Kitchen Sink - • / Water Service .' . •'• - , , "Ark Device Boxes ' Pole Light
• •Lender's 'Address! Lavatories , ' s /// /1 r •
OWNER BUILDER DECLARATION ` " - - - fT. 7P///I�`y - 2 oc'm Outlets • • ' Range / KO
I hereby affirm that 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 - - - , J/� •Switche} Sign
county which requires a permit to construct,alter,improve,demolish or repair — - ? '
any structure, prior to Its issuance, also requires the applicant'f or such permit Roof Drains' ' •- - _ Garbage Disposal ' Standing Sections
do file a.signed statement that-he/she is licensed pursuant to the provisions of - - _ - - -
'tte Contractor's License Law(Chapter 9(commencing with Section 7000)of • Generator ❑0.5 KW ❑5.15 KW Trash Compactor
;; rasion.3 of the'Business and Professions Code) or that he/she-is exempt . P •
_ ::.aefrom and the basis forothe alleged exemption. Any-violation of Section - I _ • ,
,ffi-1,5 by,any applicant for a permit. subjects the applicant :to a civil Reinspection Fee $25 Issue Fee - $ 3 •
pee malty of not more than five hundred dollars($500). - -, -
+. -1, as owner of the property or my employees-.with wages as their sole ' MECHANICAL -- Reinspection Fee • $25 Issue Fee • ' $ 3
Compensation, will tl0 the work,and the structure Is not intended or offered "' FEES -
for sale (Section 7044, Business and Professional Code:' The Contractor's PUBLIC SERVICES REQUIREMENT '
License Law does not apply to an owner of a property who builds or improves Boiler I Hood or Type I 0 ^ 9,08
employees,
thereon,and who does such work himself/herself or through his or.her own � Zoning Approved By�.!-(_JLI � Date la-
employees, provided that such Improvements are not-intended or offered for Canopy Type II 0
sale. If, however, the building or improvement is sold within one year of com- Duct-Under Ground Application Approved By iciDate / 99 n.,•.
pletion, the owner,will.have the burden of proving he/she did not build or im- - (� J� S
Q
grove for the purpse of sale). Duct-Structural Refrigeration System Application Issued,By Date•
f
• td'I, as owner of the property,am exclusively contracting with licensed con- ❑0.100,000 BTU ❑100,000 BTU
tractors to construct the project (Section 7044,Business and Professions Code: Duct-Ventilating -SUMMARY OF FEES �
The Contractor's.License Law does not apply to an owner of property who • - BUILDING PERMIT $ 9o?. SMTP $ O. a9
builds or improves thereon,and who contracts for such projects with a con- m Exhaust System 0 Multiple 0- SysteRepair/Alteration _
tractor(s) license pursuant to the Contractor's License Law). ,l PLAN CHECK $ PERMIT
Oil am exempt under Section B.& P.C.for this reason • Firepl/Fact.BIL ICRO# / �jCTif�S t�/� / Ot •PLUMBING $ / ISSUANCE $
Date Owner. Heating System&Ducting / .�'JCT / 00 PLAN CHECK § 00 ENERGY P.C. $
1 hereby certify that I have road this application and state that the above ❑0.100,000 BTU ❑100,000 BTL / .S', et0 GRADING $'4 '
information is correct. I agree.to comply- with all city and county ordinances _ _ . . . ELECTRICAL $ -
and state laws relating to building construction,and hereby authorize repre- PLAN CHECK $ ' /• 20 MICROFILM $
sentativez of this city to enter upon the bout-mentioned property for �• OO
inspection plc p
• Signature .-(% Date )1dL?/7-kS , MECHANICAL $ TOTAL FEE $ lJ • ,
a Drivers"License or SS 9F —
Accounting;Goldenrod-Assessor_ - - - ' . •
' CDNST$UCTION AND PLANNING . POC SPA
-1
APPROVALS Permit# Date Inspector APPROVALS Permit#
Date Inspector
t'17. Temporary Electrical Service or Pole 52. Pool & Equipment Location
G
2. Soil Pipe-Undrgrnd. 2_(4'{ Ate 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement ,PI/C/gY /)yLj 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 4,,/9y 3-7,4,7 57. APPROVAL TO COVER-GUNITE
7. Footings ,4 /4Y A* 58. Electrical Conduit-Undrgrnd.
8. Foundation , /i(ey is 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
v
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 3/is/Jy Ol 65. Electrical-Final
15. Rough Electrical-Conduit d 66. Solar System-Final
=
16. Rough Electric Wiring 310/ay (ie. 67. Fencing & Access Approval
17. Rough Wiring Sign l l 68. APPROVED FOR PLASTERING
,i8. Rough Electrical-T Bar Ceiling•: 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit#
'21. Ducts, in Structure . 70. Underground Hydro
22. Ducts, Ventilating .,( - 71. Product Piping 0 Gas El Oil
23. Gas:Pipe-Rough &'Test 72. Underground Flush
24. Roof Framing,•• 1 34(fsq /3-1,n 73. Undergrnd.Storage Tank 0 Gas ❑Oil .�
25. Roof Sheathing. , 2h11' '✓ ,..,8,2"..1
-' t.1. 74. Overhead Hydro
26. T-Bar Ceiling (Structural);& Monocoat I 75. Dry Chemical
27. Frame and Flashing % •olin j1-7 76. Dry Standpipe '
28. Lathing;& Siding 77. FIXED SYSTEM FINAL
29. Insulation J' 4Z// q A 78. FIRE'PREV. FINAL
30. Drywall Nailing ?' ;' ;.7.3 10,- - C HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final I 80. FOOD:CERTIFICATE ISSUED
33. Final Electric - c/6i/,, igZet7 . Notes:kOOKe, L1,vnit 3j'I. e'Ydoge
34. Final Heating & Air Conditioning rf 04y ca.' '-'v
r
35. Final Gas Pipe-Test
36. Hood or Canopy % '
37. Final Factory Fireplace .
38. Final Plumbing l //V i/V /'n 9e
39. Water Service-Final - .409
40. Gas Service-Final ..
41. Solar Domestic-Final .
42. Backflow Preventer
43. Backflow Irrigation -' - .j . I -
44. .Landscape Irrigation System `- . - '
45. Sound Attenuation •
46. Handicap Regulations '
47. FINAL STRUCTURE & BUILDING 61t/V9 B71/
48. Special Requirements Completed-
49. Electric Release to Edison - 1.
50. Gas Release to Southern California Gas Co • •�
51. CERTIFICATE OF OCCUPANCY - !3• ..
•
-
No. 4 Dale �3 1
L
! .
CITY OF COSTA MESA
BUILDING INSPECTION DEPARTMENT
77 FAIR DRIVE
COSTA MESA, CALIF. 92626
RE : ROOM ADDITION ON RESIDENCE OF
CHARLES M. BROCKERT
1612 PRIMROSE
COSTA MESA, CALIF . 92626
• The room was accurately surveyed and the land
little disturbed . To the best of my knowledge the
grading remains in full compliance of City Specifications .
//lle
4(17M, air /
CHARLES M. BROCK RT
OWNER-BUILDER
1
DEVELOPMENT SERVICES/BUILDING SAFETY DIVISION
ON-SITE GRADING STANDARDS
1. EACH PLAN OF DEVELOPMENT SHALL HAVE A GRADING PLAN WHICH WILL
INDICATE THE DIRECTION OF FLOW TO THE NEAREST STREET OR STORM
DRAIN FACILITY .
2 . THE GRADING PLAN SHALL SHOW THE FOLLOWING GRADES :
Two PERCENT (2%) AWAY FROM ALL STRUCTURES FOR A
DISTANCE OF FIVE FEET (5' ) MINIMUM, ON ALL SURFACES .
ONE PERCENT (1%) SLOPE FOR ALL BARE EARTH SWALES AND
ASPHALTIC OR PORTLAND CEMENT-PAVED CONCRETE SWALES
BETWEEN STRUCTURES, WHICH ARE FIVE FEET (5' ) FROM
ANY STRUCTURE .
PORTLAND CEMENT CONCRETE DRIVEWAY SWALES, GUTTERS,
AND SIMILAR CONSTRUCTION SHALL BE ALLOWED TO SLOPE AT
THREE-TENTHS PERCENT ( .3%) PER FOOT, PROVIDED THEY
ARE A MINIMUM OF TWENTY-FOUR INCHES (24") IN WIDTH ON
THE WATER-CARRYING SURFACE .
3. IF A STORM DRAIN FACILITY, SUCH AS A PIPE, SWALE, OR DITCH,
LEAVES THE SUBJECT PROPERTY IN ANY MANNER WHATSOEVER, ENTERS OR
CROSSES ADJACENT PROPERTY(S) , IT SHALL BE WITHIN A RECORDED
DRAINAGE EASEMENT ACROSS, THROUGH, OR UNDER THE ADJACENT
PROPERTY(S) .
THIS RECORDED DRAINAGE EASEMENT SHALL BE CONTINUOUS FROM POINT
OF ORIGIN TO A POINT OF TERMINATION ACCEPTABLE TO THE PUBLIC
SERVICES DEPARTMENT .
PUBLIC SERVICES DEPARTMENT ACCEPTANCE SHALL BE IN WRITTEN FORM.
4. THE CIVIL ENGINEER WHO PREPARES THE GRADING PLAN MAY DESIGN
TO LESSER SLOPES AND GRADES PROVIDED THAT :
THE ENGINEER SHALL PLACE OVER HIS WET INK SIGNATURE ON
THE FIRST PAGE OF THE SAID GRADING PLAN THE FOLLOWING
STATEMENT :
"I HAVE PERSONALLY INVESTIGATED THIS SUBJECT SITE
AND HAVE PREPARED THESE PLANS BASED UPON THE CON-
DITIONS FOUND, AND IN MY BEST ENGINEERING
JUDGMENT THESE PLANS WILL PROVIDE FOR ADEQUATE
DRAINAGE OF THE SITE . "
'um.
(OVER) I
.
5. THE ENGINEER PREPARING THE GRADING PLAN SHALL PERSONALLY
INSPECT THE GRADED SITE IMMEDIATELY PRIOR TO REQUEST FOR FINAL
BUILDING INSPECTION, AND IF PROPERLY GRADED ACCORDING TO HIS
GRADING PLAN, SHALL PROVIDE A LETTER OF CERTIFICATION TO THE
BUILDING DIVISION FOR PERMANENT FILING, STATING THAT ALL WORK
WAS ACCOMPLISHED ACCORDING TO THE APPROVED GRADING PLAN ,
IF ERRORS ARE FOUND BY THE ENGINEER, IT SHALL BE THE RESPONSI-
BILITY OF THE ENGINEER AND HIS PRINCIPALS TO CAUSE THOSE ERRORS
TO BE CORRECTED PRIOR TO FILING THE LETTER OF CERTIFICATION .
6, ALL UTILITY RELEASES SHALL BE WITHHELD UNTIL SUCH TIME AS THE
LETTER OF CERTIFICATION IS ACCEPTED BY THE BUILDING OFFICIAL .
J
w
City of Costa Mesa INSULATION CERTIFICATION Building Safety Division
/% /a n
lir� s l Oc4 New or ,v4 P
Number and Street City County
Subdivision Lot Number
DESCRIPTION OF INSTALLATION
ROOF/ cc/A/6'
/ �if/
Material �'�^" Brand Name `9 pi/��J ` sc� A�
// /
Thickness (inches) C�/� / Thermal Resistance IR Value)
EXTERIOR WALL n
Material W�.0 /°62.4-(5h'A77 Brand Name _7---2Y 6CALC L22,4N AN 6-
Thickness (inches) 1,37 w Thermal Resistance (R Value) —//
CEILING
Batt ro Blanket Type Brand Name
Thickness (inches Thermal Resistance IR Value)
Loose Fill Type Brand Name
Minimum Thickness (inches) Number of-bags Weight per bag lb.
Area Covered (ft2) Thermal Resistance
FLOOR,.ELEVATED
Material Brand Name
Thickness (inches) Therma�tance'((R.Valuel_.__—._____ __
FLOOR,SLAB/"
Material CLING• Brand Name
/
Thickness (inches) Thermal Resistance (R Value)
Width (inches)
FOUNDATION WALL
Material Brand Name
Thickness (inches) Thermal Resistance (R Value)
DECLARATION
I hereby certify that the above insulation was installed in the building at the above location in conformance with
the current regulations setting Energy Conservation Standards for new residential buildings (located in Title 24
of the California Administrative Code).
(54a//e5 M . /3 vac �C�r � u/f� P� 3 [.f /%
General Con$t( :ctor(Builder) License Number
AA •sL b
Signature and Title Date
Sub Contractor (Insulation Applicator) License Number
Signature and Title Date
CMF 1106-30
r 10076 .
AUG 7 1959
COSTA MESA BUILDING-SAFETY DEPARTMENT
'7-1'-
P.O.BOX 317 COSTA MESA. CALIFORNIA _ ..
FOR APPLICANT TO FILL IN COMPLETELY APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
BUILDING
ADDRESS 1612 Primrose St.
•
COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY
OWNER Ro'1((ssvlane�/Lancd Co. RECEIPT NO. I �PUp.^
AMAILDDRESS 419 E. 17th St. �f��''II pp RECEIY$D BY I DATE.RECEIVED I/Illu 1 IUB1s1LV�s
CITY Costa Mesa TNO.1,141.57 ADDRESS
ARCHITECT
%y (/ /'l l!
ARCHITECT Carlson & LIC. COSTA MESA. CALIFORNIA
OR ENGINEER NO.
I•hnulebrook --
FIRE '/ _
CTP rflPn Grave ZONE TYPE -P�'�"
ADDRESS GROUP
CON R ]�O
P� FfC Colegrove, Inc. STATE
NO. 167293 APPROVED
St.,LIC. BY DATE
ADDRESS 419 E. 17th St., Costa Mesa ZONING
LEGAL I LOT 180 I I 2822 ZONE NO.OP UDE OF NEW /✓J^
DESCRIPTION NO. BLOCK TRACT I I Puna 2 I emLDING T Y,,.
APPROVED `/ Jam,/v/—/ f'
A.P.NO. BY 7� �J[ mut J/4 S e,
SIZE •1 NO.OP SLDGS. YARDS EVES
OF LOT 65 X 100 nOw Ory LOi none REQUIRED ALLOWED
USE OF (CENTER LINE ST.)
EXISTING BLDG. FRONT S"'/J FT. IN.
SETBACK LINE FROM
CENTER OF STREET 5 REAR YARD 31 R.SIDE FT. IN.
SIDE YARD I LEFT 9! I RIGHT 61 L.SIDE Y! FT. IN.
DESCRIPTION OF WORK REAR .2-.9 Fr. IN.
NEW I X II ALTERATION I II ADDITION I
REPAIR I II MOVING • I II DEMOLISH I
BSIZE
1560 NO.OF
ROOMS 7 STORIES 1
EXTERIOR WALL.ttCCo I ROOF
COVERING COVERING rock
USE OF BUILDING AND WORK TO BE PERFORMED
Single family residence with
attached garage.
Plan 120A
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CON•
PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
BUILDING CONSTRUCT N. VALUATION
SIGNATURE OF PERMIT FEE $ 35.00
PERMITTEE
$ 15,571 PLAN CHECK $ 17.50
AUTHORIZED AGENT Dike & Cole Frove.jnc. TOTAL FEE $ 52.50