HomeMy WebLinkAbout1125 DENNIS DR - Building PermitsCITY OF COSTA MESA ;
BUILDING DIVISION
F77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-niesa.ca.us
FOR INSPECTIONS CALL: (714) 754.5626
•44%a.nm �`�
PERMIT NUMBER: P08-00157
PERMIT TYPE PLUM
STATUS: ISSUED
APN: 41207453
DATE ISSUED: 06/27/2008
OWNER:
ISSUED BY: YH
JOB ADDRESS: 1125 DENNIS.DR CM
Suite/Unit:
Vicinity: - -
-
SCOPE OF WORK: REPLACE WATER HEATER WITH SAME SIZE WATER HEATER/SAME LOCATION
CONTRACTOR: ALL STAR WATER HEATERS INC License No. 812894
Address: 30300 PUERTO VALLERTA
PHONE: 800-727-0977
City/State: MENIFEE, CA ZipCode: 92584
ARCHITECT:
ENGINEER:
License No.
License No.
CELL:
PHONE:
PHONE:
PLUMBING PERMIT FEE SUMMARY
PLAN CHECK FEE-.,
PERMIT FEE:
TOTAL FEES:
$0.00-
$35.80
$35.80
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.
OE t. INSPECTION TYPE DATE lmTlAL CODE/ INSPECTION TYPE DAW - INnnALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical 3 1�
1286 Pool Spa Final 208 Final Plumbing I �7 , JI , OS B
200 Final Re -Roof 210 Final Electrical
.201 Final Olock/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
x
OWNER:
BRYAN, GARY D -
Address:
1125 DENNIS SR
PHONE:
-
City/State/Zip:
COSTA MESA, CA
APPLICANT:
LINGFORD, SEAN
- - ' Address:'. -
30300 PUERTO VALLARTA ,t
PHONE:
800.727-0977 Tc
City/State/zZip:
MENIFEE, CA
CONTRACTOR: ALL STAR WATER HEATERS INC License No. 812894
Address: 30300 PUERTO VALLERTA
PHONE: 800-727-0977
City/State: MENIFEE, CA ZipCode: 92584
ARCHITECT:
ENGINEER:
License No.
License No.
CELL:
PHONE:
PHONE:
PLUMBING PERMIT FEE SUMMARY
PLAN CHECK FEE-.,
PERMIT FEE:
TOTAL FEES:
$0.00-
$35.80
$35.80
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.
OE t. INSPECTION TYPE DATE lmTlAL CODE/ INSPECTION TYPE DAW - INnnALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical 3 1�
1286 Pool Spa Final 208 Final Plumbing I �7 , JI , OS B
200 Final Re -Roof 210 Final Electrical
.201 Final Olock/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: "
I hereby affirm under penalty of perjury one of the following declarations: .
❑ 1 have and will maintain a certificate of consent to self-Insure'for workers'
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
El,"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' cora sation Insurance carrier and policy
number are: /
Carrier.
(This se[ w nese Trot he pamp'etea Ilse perms is vatueu at one munenxi "am (Sim); less.)
Policy Number: ( T6 I "/ y >—
❑ 1 certify that in the performance of the work for which this permit is
issued, I shall notemploy any per on in any manner so as to become subject
to the workers' compensation I of California, and agree that if I should
mi
-kers' subject to the kers' ompensation provisions of Section 3700 of
the Labor Code, I hal rthwi mply with these prowsi ns. /// Y
---zm-
Ap rli Sig ture Date
WARNING: fAILUOt V SECURE WORKERS' COMPENSATION COVERAGE
IS UNLA L AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, 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 to and If t. J
p- p �i L
Lic. # 0 f �0 A Class # C
rattor's Signature ' Date
CO9ISTRUCTION 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 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.).
❑ lam exempt under sec.
Business and Professions Code for this reason:
Owner ID verified by drive. „ ecense. ❑ Yes ❑ No
Driver's License No. Expires:
Verification of Ownership by (type of document, i.e. - property lax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a
person is required to descend, will be made in connection with work authorized
by this permit, and that no building structure, scaffolding, falsework, or demolition
or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp
2, Art 2, Sec. 311, 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.
Apperant's Signature
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to file and
certify a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some
exceptions, that a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
500 pounds. or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard temperature and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
hazardous materials equal to or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
temperature and pressure).
3. Does or will the applicant or present or future building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the
Costa Mesa Fire Department may require the preparation, certification and
fling with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
4. If an RMPP is presently required, has Section 25534 of the California
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require for
the work which is the subject of this 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? ❑ Yes ❑ No
(Section 65850.2 of the California Government Cade requires that the requested
information be furnished on applications for non-residential building permits).
6. Will any part of the facility to be constructed under this permit be within
1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If "yes", the facility must meet the requirement of Sections 25534 and 42303
of the California Health and Safety Code).
7. If a permit from the South Coast Air Quality Management District or other
air pollution control district or agency is required for the work which is the
subject of this application, have all of the disclosures prescribed by California
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
8. (If "yes', attach certificate of compliance from the appropriate air pollution
control officer). -
CERTIFICATE OF COMPLIANCE:'I certify that under penally 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 p occupy or allow occupancy of any building
authorized by this permit until f tl inspection.
Si aWreo al qs) ate
Signature Data 305]-O6 (3,07)/or lit nze Applirant Date
CITY OF COSTA MESA
A��T°"'Fs, BUILDING DIVISION
i 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
FOR IN.iXECT:4NS CALL: (714) 754-5626
PERMIT NUMBER: Mll-00059
PERMIT TYPE MECH
APN: 41207453
STATUS: ISSUED
DATE ISSUED: 04/25/2011
ISSUED BY: KJB
JOB ADDRESS: tc1125 DENNIS DR CM Suite/Unit:
Vicinity
SQ. FT: 0
SCOPE OF WORK: FAU CHANGE OUT. 90K BTU. SAME LOCATION
OWNER:
BRYAN, GARY D
Address:
1125 DENNIS SR Unit:
PHONE:
$0.00
City/State/Zip:
COSTA MESA, CA
APPLICANT:
LAW, JOHN
Address:
Unit:
PHONE:
949-795-5128
City/State/zZip:
CONTRACTOR: D G LAIR CONDITIONING AND HEATING
License No. 622345
Address:
1235 W COLLINS AVEUnit:
PHONE: 714-279-9480
City/State:
ORANGE, CA ZipCode: 92867
CELL: '
MECHANICAL PERMIT FEE SUMMARY
MECH ITEM FEE:
$38.30
PLAN CHECK FEE:
$0.00
INVESTIGATION FEE:
$0.00
REINSPECTION FEE:
$0.00
TOTAL FEES: $38.30
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. W-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 1. INSPECTION TYPE DATE INTITIALS CODE 1 INSPECTION TYPE DATE t�TIAL
�g
1616 Fixed System Final Fire Prevention 206 Final Mechanical ,x S�j —1 v V�)OLQ
1266 Pool Spa Final 208 Final Plumbing I
200 Final Re -Roof 210 Final Electrical
201 Final BIocWRetaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final BuildinglOccupancy
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
pert ante of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
se n 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: re A
(This section need, not be completed, nine permit is valuec al one hundred Collars ($100) or less)
Policy Number: Lt-_�G Z V 9Q S sici
❑ 1 certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to the workers' compensation laws of California, and agree that if I should
become su to the worke co pensation provisions of Section 3700 of
th o ode, shall forth ith c ply with these provisios.
41 1
Applicant's gnature 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 DOLLARS
($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.# Z3�S Class# GZC7
Ilk Contractor's Signalure
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Address:
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 rile 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 contmclor(s) license pursuant to the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
Signature Date
305716 (3/07)
Owner ID verified by drivo.., license. L] Yes ❑ No
Driver's License No.
Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DI�SIONAF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ Thereby 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, a demolition
or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp
2, Art 2, Sec. 341, Title 8, 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.
Applicant's Signature Date
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to file and,
certify a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the California Health and, Safety Code requires, with some
exceptions, that a Business Plan be fled with the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard temperature and pressure).
2. Does or will the applicant or present or future building occupant need, to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and, Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hand, a quantity of acutely
hazardous materials equal to or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed, gas at standard
temperature and pressure).
3. Does or will the applicant or present or future building occupant need to
prepare an RMPP (Risk Management and, Prevention Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the
Costa Mesa Fire Department may require the preparation, certification and
fling with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
4. If an RMPP is presently required, has Section 25534 of the California
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require for
the work which is the subject of this 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? ❑ Yes ❑ No
(Section 65850.2 of the California Government Code requires that the requested,
information be furnished on applications for ran -residential building permits).
6. Will any part of the facility to be constructed under this permit be within
1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If "yes", the facility must meet the requirement of Sections 25534 and, 42303
of the California Health and Safety Code).
7. If a permit from the South Coast Air Quality Management District or other
air pollution control district or agency is required for the work which is the
subject of this application, have all of the disclosures prescribed by California
Health and, Safety Code Section 42303 been made? ❑ Yes ❑ No
8. Of '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 stale 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.
aWr pf Leg ner s / ate
tic[ Z
And/or Author -red Applicant t Date
wF
CITY OF COSTA MESA -
�` BUILDING DIVISION PER NUMBER
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
•699-01278
(714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 1125 DENNIS DR
Suite:
Vicinity:
HOUSE & GARAGE
Parcel Nunmber:
41207453
Applicant:
MILLENNIUM ROOFING
Address:
801 RANCH VISTA RD.
- _ FEE SUMMARY
CA
Plan Check:
CORONA
—
Calc Valuation: $5,000.00
Owner:
BRYAN, GARY D'
Address
4950 SUNBIRD CLIFFS DR ,
SMIP Res:
COLORADO SPRINGS, CO -
Contractor:
MILLENNIUM ROOFING
Address:
801 RANCH VISTA RD.
CA
Other:
CORONA
Zip:
91719,
Arch
Zoning: R1 R1
Phone • (909) 278-4888
Zip: 91719
i
Phone:- - -
Zip: 80919
Status: ISSUED
Applied: 08/12/1999
Issued: 08/12/1999
ISSUED BY:
Phone: (909) 278-4888
License: 758692 '
Eng: CHARLES A JOHNSON JR
Address: - - Address: PO BOX 6284
" Phone: - Phone: (714)898-6180
GARDEN GROVE; CA
F
Zip: --� License: 92846 License:
SCOPE OF PERMIT
REROOF - T/O, INSTALL 1/2" OSB BOARD,' 2' LAYERS OF 30# FELT & PIONEER LIGHT WEIGHT TILE
ICBO # - - -. - _ - 1.'
- 3748.
,
- _ FEE SUMMARY
Plan Check:
$72.31
—
Calc Valuation: $5,000.00
Permit:
$111.25
Claim Valuation: $5,000.00
SMIP Res:
$0.50
,r
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total:
$184.06
PLANNING•& ZONING
.. -
SETBACKS
MAIN STRUCTURE .Front 0-0
Rear 0-0 Left 0-0
Right 0- 0 -
ACCESSORY
Front 0-0
Rear 0-0 Left 0-0
Right 0-0
PARKING
Existing: 0
Required: 0 Proposed: 0
NOTES:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia 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 sell-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the pertormance of the
work for which this permit is issued.
�( I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carder and policy number are:
Carder: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars ($100) or less.)
❑ 1 certify that in the pertormanc 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 C6II ni an 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 provi ion . S-
(� - q
Applicant Signature: `` Date:
WARNING: FAILURE TO SECURE WO KERS' COMPENSATION COVERAGE IS UNLAWFUL AND SMALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN BION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed und¢rp{pvisions 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.# 6L7d Class#
Contraclors Signature: 1 Date: k (�
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:
Signatura: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself of 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 Lew does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires:
Verification Of Ownership by (type of document, i.a. - property tax bill Or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereot, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner•builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present Or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous matedals7 ❑ 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 tiling 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 oru present or future District
occupant require for the work which is the subjectage c this application a Eermit for such construction or motlificatlon
tram the South Coast Air Quality Management District or from any other air pollution control district or agent)? jJ Yes jJ NO
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be Constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
8 (If -yes-, attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty Of perjury the information given above is correct. I agree to comply with all slate laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. I agree not to occupy or allow occupancy Of any building authorized by this permit until final inspection.
ignatur Of Legal Owner(s) C (-1 Dat Q
And/Or Authorized Applicant b 1 eC Date J
CODE I, 2aeJ _91I1PE INTRIAL$ CODE E INSPECTION TYPE DAFT INTMA
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 6z 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
2446.48
CITY DF COSTA MESA
CAL eNIA 92E26 F.O. IFOx 1200
FROM THE OFFICE OF THE DIRECTOR OF BUILDING SAFETY
Project Address �� 7_-) 11�P 411ti ,Q1'
Project Name
Owners Name
Owners Address z/G S Or
Owners Telephone
Permit # So 333
0
City Use Only
I zee::2 <-�as Owner, Contractor, Agent (strike out all
except one) do hereby attGet that cloyment of any person, or persons, is not
anticipated at the time of seeking the above -referenced permit. In the event that
any person, or persons, are employed under the provisions of this permit, I shall
immediately cause a valid Certificate of Workmen Ccupensation to be filed with the
Costa Mesa Building Division.
I agree to defend at my own cost, and to indemnify and hold harmless, the City,
its officers, agents and/or employees, from and against, any and all liability,
damage, costs, losses, claims and expenses, howsoever caused, resulting directly
or indirectly from, or connected with the improvement under this permit.
I further state that I have read and fully understand the implications and re-
sponsibilities of the above statements, and will coyly with all provisions of the
Contractors State License Law found under the Business and Professions Code,
Division 3, Chapter 9, of the State of California.
Print Name
Sign tua
CMF 0777.46
�Oate'/'
COSTA MESA BUILDING -SAFETY DEPARTMENT APPLICATION FOR STRUCTURAL PERMIT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For
REC V D in;a5Q3I
Applicant to Fill in Completely — Use Ink Only
ADDRESS L BUILDINGc f y%
A.P. NO. — Q7�. -
OWNEROR
e�
ADDRESS
�,�, f..._C'
MAILING
�'�' �"
UNIT NADDRESS
SPACE NO.LOT
CITY �% NOL.'
/�NEW
AD ALTER REPAIR MOVING
DEMCONSiRUCiIONLENDERBRANCH
toOWN
RADDRESS
f VALUEARCHITECT
2
TEL.
US $
OR ENGINEER N
Pv
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ADDRESS
'ZUN E�—� YPE GROUP
APPROVED
7 O
CONTRACTO �° e, —
BY DATE?
L
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ADDRESS
TEL,., �
CF
CITY NO_
STATE Q CITY
APPROVED SETBACKS
LIC. NO. LIC. NO.
/-fG
SIZE NO.OF BLDGS.
IFROM C/L STREET �^
OF LOT NOW ON LOT
FRONT
USE OF
/I /
6
EXISTING BLDG.
FT.
Separate permits are required for
L. SIDE / / FT. O
electric, plumbing and heating work:
�r
/FT.
REAR O
USE OF BUILDING AND WORK TO BE PERFORMED
PLANNING ACTION
DATE
®
APPROVED
ED
1263:E 7 42
C)
1 hereby acknowledge that I have read this application and state
that the above information is correct and agree to comply with
all laws regulating building construction, and I shall not employ
any person in violation of the workman's compensation laws of
the State of California.
1 hereby certify that I am properly licensed as a contractor under
SO. FT.
the State of California Business and Professions Code, Division 3,
THE AMOUNT SHOWN UNDER VALUATION
IS FOR
Chapter 9, and that such licenses are in full force and affect, or I
THE PURPOSE OF ESTABLISHING A PERMIT
FEE ONLY:
am exempt from the provisions of the State of California Business
VALUATION PERMIT FEE $
s dd
and Professions Code, Division 3, Chapter 9.
PLAN CHECK $
Signature of
t1_ 0,
Permittee
$ -7 q TAX $
0. 3�
or
Authorized Agent Date
TOTAL PAID $
50. TL
OWNER WILLIAMS, MR. DATE 7_7_80
.JOB ADDRESS 1125 Dennis Drive BUILDING PERMIT NO. 50333
b. 419_n79_
MAS
WATER
Ij ROUGH
PROPROP.
..v
LINE I I HOUSE CON.
UNDERGROUND POWER
ROUGH WIRING
ITIONING
STEEL REINF.
FLOOR SYSTEM
BOND BEAM [-1 STEEL REINFORCE
SHEATHING
FRAME AND FLASHING
LATHING - INrl
PLASTER, BROWN COA
_i TURAL, FINAL
H, HG. VENT., REFI
0
BUILDING, FI
SUBCONTRACTOR
f77-
45020
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA, CALIFORNIA 92626
r For Applicant to Fill in Completely — Use Ink Only
BUILDING IIZS )r1VNk/
ADDRESS
es west Development Corp
MAIL
CITYNew ort Beach Ca. NY6 -4 1
CONSTRUCTION
LENDER
BRANCH
ADDRESS
ARCHITECT TE
nv crur:,ucao Frank SDanLTler tiM73 09 K2
CONTRACTOR Owner
ADDRESS
TEL.
CITY NO.
F STATE CITY
LIC. NO, SIZEp LIC. NO.
A. of LOT Approx . 60 , x80 r NOW ON LOS 0
Q USE OF
EO EXISTING BLDG.
VJ
Separate permits are required for
electric, plumbing and heating work.
USE OF BUILDING AND WORK TO BE PERFORMED
Q
D
a Construct single family bedroo
house Plan
a
w
0 10-77F; Ic00 *
c asa 554* ** 109.78
APPLICATION FOR STRUCTURAL PERMIT
BUILDING
ADDRESS
rom
Properties West Dgelopmen
OWNER orT�.
S Res. Atd, Or, VALUE$ 61,100
FIRE
ZONE YPE GROUP
APPROVED
BY DATE —
NO. OF USE OF
PLANS BUILDING �
YARDS APPROVED YARDS YARDS APPROVED YARDS APPROVED
MAIN BUILDING ACCESSORY BUILDING
VAR. #
C.U.P.,
rsLsviz
I
4
.z
3
1 hereby acknowledge that I haver this appllcfktion and nate
that the above Information Is correct and agree to comply with
all laws regulating building construction, and I shall not employ
any person In violation of Me workman's compensation laws of
the Sura of California.
1 hereby certify that I am properly licensed as a contractor under
the State of California Business and Professions Code, Division 3,
Chapter 9, and that such licenses are in full force and effect, or I
em exempt from the pr. visions of the State of California Buslnen
antl Professions Cod: 'vision 3, Chapter 9.
Signature of - �y-Js
Permittee' `�J '�/
N
w
'
m
H
sip
g
0
U
^ n
OI-'� fO� SPEC;
t
rt (r+ wa ;
,� RK el.[... 151
SO. FT. 2 2
THE AMOUNT SHOWN UNDER VALUATION IS FOR
THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
VALUATION
$ 61 s 100
PERMIT FEE $
PLAN CHECK $105-50
TAX 4.2EIi
�//®®
TOTAL PAID $
Authorized Agent /��b Gci e..c•U-cv�