HomeMy WebLinkAbout1114 EL CAMINO DR - Building PermitsJob Address: 1114 EL CAMINO DR Status: ISSUED
Suite No Applied: 12/08/2006
Vicinity: Issued: 02/14/2007
Parcel Nunmber: 14161216
Applicant: AUGUSTINE, ROBERT LTR
Address: 1114 EL CAMINO DR
COSTA MESA, CA
Phorie:- "
Zip 92626
Owner: AUGUSTINE, ROBERT. L TR
Address 71-14 EL-GAMINODR
Phone
COSTA MESA, CA "- -"Zip:
Contractor:
Address:,
Phone:
„l ✓ Zi
License:
92626
ISSUED BY:
SCOPE OF PERMIT `
.360,SF ADDITIONTO EXTEND KITCHEN AND RELOCATE FRONT ENTRYREF: B06-02044
ELECTRICAL TO INCLUDE: 13 LIGHT FIXTURES, 14 OUTLETS, AND 6 SWITCHES.
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 s -
oma -46 rwnm
FEE SUMMARY
i
r,
Quantity/ ��
.
"-' -' -: � �-
Quantity
(ISSUE FEE
$23.50
- '` - - i" -
�,
-Temp/Dist System`/ Lighting_
$0.00
_
0 _
' Temp service test
$0.00
_r
-
_
Busway /100 ft -_
$0.00
0
Res. a/c package',
$0.00
` - -
Standing Section
$0.00
0 "
New Res (1-2 units)', _
$0.00
", 01 ,._:r,� _
Misc Electrical, Equipment _
$0.00
0
New Res(3+units)",, 1.
$0.00
r0___=+_.-____
Transfomers.upto.l kva/kw_
$0.00
Pool I Spa
$0.00
_ ,
0
Lighting Fixta
$14.30
, 13
...........up to 50 kva/kw
$0.00
0
Recepl Outlets '
$15.40
14
...__.._. . ��up to 100 kva/kw
$0.00
0;' '
Switches
$6.60
6
..............:...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_Conduil
$0.00 „ .;
0
Service to1006a\$D
00
��$0.00
0 w` T -
Misc. Conductor
$0.00
" 0 -
Service over 1000a �ti,
0 „'
r Circus (gen'dr:iide)
$0.001%,,
0 "
Motors to 1hp -,
"$000
_ -.0,":-'
Circus(meth ride;or lights).--=--
$0.00'
0
Motors to 10hp `
$0,00"
0
Christmas Tree Stand -
$0.000
Motors to 50hp
'$0.00" '
��``
0-
_Fireworks Stand-.
;$0,00/"
0
Motors to 100hp ;�\ �/
$0s00
<i
�0��,. > .�
'Othe'r Electrical, Fee -
��
$0.00
Motors over 100hp� -
$000
�� OAC
Communication drops, ��V
'��$0.00�
0��� `�.r„ -
- Investigation Fee.
moo ;
Sub panel to 200a
�'-
��,$000
`- �-
. 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 $59.80
Intermed Pole
$600-
0
-
" -'COMMENTS I SP.ECIAL'CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626 s -
oma -46 rwnm
n
Adh
DECLARATIOMS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(this sec ' n need no plated i/ the permit is valued of one huntlred dollars ($f 00) or less.)
I cartity that i th rt rice the ork for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensatio I sof lifomi , end a ree that if I should became subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith
comply with t es pr i on ////
Applicant Signature: '-- �— Date: 6'L _ � 'Y _�
WARNING: FNLURE TO SECURE WORKERS' PENSATION COVERAGE IS UNLAWFUL AND SHAM SUBIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FlNES UP TO ONE HUNDRED
THd1SAND DOLLARE (5100,0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'$ 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 #
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that theta is a construction funding agency tot 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
Cade: 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).):
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. IL however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ 1, as oMdnvers
am EXCLUSIVELY.CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 70", Business and Professions
Code: lc se does not apply Nc
an owner of property who builds or improves thereon, and who contracts for such project with a contractors)
ens tractors License Laws.).
lam a or Business and Professions Code for this reason:
Signature:-� //Date: B 2 '—' � �
Owner ID vicense. ❑ Yes ❑ Driver's License Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap, 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to retease 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 fits a registration form for acutely hazardous materials? ❑ Ves ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
...................................... _................................................................... ...................................................... ................................................................................................ .............. ............................................................................................................
3 Does or will the applicant or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
.......................... _........... _........... .................... _._-..............-..............................................................................__......................................................................................................................................................._................................
4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
......................................................................................................................................__ ........................................................................................-................................................................................................................
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aaermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? BY LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
............................._........._..........._........_,._................................................................................................................................_..-_....... ........................... ........................................ _......................... ......................
8 Will any part of the 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).
..Y...................................................................................................................................................................................................................................................................................._.............................................
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
....._ ......................... ............. __......... _..... I--. ..................... ...._....................................................... —.......................................... ... ......... ..... .............. .............. ...... ........_.................................................. -.................. ....................................
6 (If yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: 1 certify that under penalty of perjury the information given above is correct. 1 agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFl ATE C 11 E lfiHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I ogre to ply wi all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above -d son Op rt r r Inspec' purposer9 of to occupy or allow occupancy of any building authorized by this permit until final insp�tion.
a.Z li,�l—O 1
Sign lure Of Legal Owners) Date
And/Or Authorized Applicant Date
CODE r. INSPECTIONTYPE DATE INTMALS CODE INSPECTION TYPE PAR jErALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 - Final Site
204 Final Demolition 250 Final Building/Occupancy
Job Address: 1114 EL CAMINO DR Status: ISSUED
Suite: Applied: 12/06/2006
Vicinity: FRONT OF PROPERTY Issued: 02/14/2007
Primary Occ: R3 Type of Construction: V -N
Parcel Number: 14161216 Zoning:
Applicant AUGUSTINE, ROBERT L TR
Address: 1114 EL CAMINO DR
Owner:
Address
Phone: 714.557.5354
COSTA MESA, CA _ - ;i -,r.: _Zip:. v92626- - _ ISSUED BY:
AUGUSTINE;, ROBERT L TR
1114 EL CAMINO DR', =
Phone '714:557 5354
CO3�TA MESA, CA � t Zip 92626
Contractor_ -:,OWNER -BUILDER -�- - -
i
Phone:
License: 000000
'Arch ROGER XREYNOLDS Eng:
Address: � 1365 CAMINITO GABALDON Address:
r
TEPhone: 619291.3666
SAN DE IEGO, CA -
+Zip; X921081-(-, - .License �C10935 >
SCOPE OF PERMIT
360 SF ADDITION TO EXTEND KITCHEN AND RELOCATE FRONT ENTRY.
t, . - FEE SUMMARY
Plan Check" _ $313.72
Permit' $482.65
SMIP Res:$3.39,
SMTP Com $0.00,
Other. $0.00 ,
inspection:', _ $0.00 _
Total: Y $799.76 ,
.Phone:
r 'License'.
Calc Valuation:
.t Claim Valuation:
r�r�rvry uv� a wivnv� ,
SETBACKS
MAIN STRUCTURE -Front �6-0 Rear .,15-A, _ Left, `5-`0 Right 7-0.i
J - ate
ACCESSORY -' Front-•^,.�.< Rear 0-0Left 0-0 c 'Right.; -0-0 '
PARKING\ Existing,. 0 Required 0- Proposed: 0
i
$33,908.80
$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 cflhi sVpermit.
FOR INSPECTIONS CALL: (714) 754.5626
2446.46(6'00)
i
Adh
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' corppensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carrier and policy number are:
Carder: Policy Number:
(This section need not be completed i/ the permit is valued at one hundred dollars ($100) or less.)
certify that in the rfo nm ork 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 of all a, a d ag a 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 ' ns. — ` / I ,q
Applicant Signature: Date: — d /
WARNING: FAILURE TO SECURE WORKERS' MPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE (S10D,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
force and effect. Lic. a Class N
Contractors Signature; Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
1 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).):
0--1-as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, es o er o p am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business antl Professions
Cod .The nt ct s w does not apply to an owner of property who builds or improves thereon, antl who contracts for such project with a conlractor(s)
lice s_e pu uan to the C trecto License Laws.).
�m exam u der Business and Professions Cotle for this reason:
Signature:
Expire -" / �
Verification of Ownership by (type o document, i.e. -property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
...........................................................................................................................................................................................................................................................................................................................................................................................
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Ves ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
........................ ..................................................................................... ............... ._.......................................................................... ......... .......................................................................... ....................................................... .........................................
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 ❑ Ne
(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.
............................................_............._................................................................................................................_..................................................................................................... ............................................_...............................................
a II en RMPP is Presently required, has Section 25534 of the California Health and Safety Code been fully complied with! ❑Ves ❑ No
5 Does or will the applicant orpresent or future building occupant require for the work which is the subject this implication apermlt for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency?
y? Ll Yes LJ No
(Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits).
........................ _... ......... _........................_......_..............._................_I............................................................................................................................................. _
6 Will an art of the facility to be constructed under this ennit be within 1000 feet from the outer boundaries of a schocly
Y P N P ❑Yes ❑ No
(If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
..................................................................................................................................................................................................................................................................................................................................................................................
7 W.W.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
..............._......._......ttach....ertif.._...............___........................___"".___.-..____.._._..............................offi.........._............................_..__.._._.............................__...__...._............................................................................
8 (if "yes, attach ceRificate 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:
CERTI(1agr
E OM ANCAND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct e o co ply with a stale laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above- a pro a for ins ction purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
g —f-- a z— /4 -6 7
I Ignature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE t. INSPECTIONTYPE DALE INTfMLS CODE INSPECTION TYPE gdTEINTrnALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical=t/
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
G;ry4eaaaWej464" yD4e&�
gas
OWNER—BUILDER
VERIFICATION
Address: 1 (14 CL C/4,-, i NO 19,41, Permit#: 5ob—D2-n214-
A city or county, which is required to give notice pursuant to Section 19830, shall attach to such notice, and, as
a condition precedent to issuing a building permit, require the completion and require the return of, an owner -
builder verification.
Attention Property Owner:
An `owner -builder' building permit has been applied for in your name and bearing your signature.
Please complete and return this information in the envelope provided at your earliest opportunity to avoid
unnecessary delay in processing and issuing your building permit. No building permit will be issued until this
verification is received.
I. I personally plan d major labor and materials for construction of the proposed
property improv m t. ❑ No
Z. I (have/have not) — med an application for a building permit for
the proposed work.
3. 1 have contracted with the following person (fine) to provide the proposed construction:
Name
Address City
Phone ( ) Contractor's Lic. No.
4. 1 plan to provide portions of the work, but I have hired the following person to coordinate,
supervise and provide the major work:
Name
Address City
Phone ( ) Contractor's Lic. No.
5. I will provide some of the work but I have contracted (hired) the following persons to
provide the work indicated:
Name Address Phone Type of Work
1D42-46 (Rev. d/04)
I hereby affirm that I have received a copy of the information set forth in Section 19830 of the State of
California Health and Safety Code and have completed the above information to the best of my personal
knowledge, in compliance with this State law.
Signed
Name:
C.D.L. #
Date:
For more information call City of Costa Mesa Building Division at (714) 754-5273.
104246 (Rev. 11104)
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
MECHANICAL PERMIT
Job Address. 1114 EL CAMINO DR
Suite No
Vicinity:
Parcel Number:
14161216
Applicant:
AUGUSTINE, ROBERT L;TR
Address:
1114 EL CAMINO DR
Phone: '
:ISSUE FEE r
COSTA.MESA,�CA--
Zip: 92626 '
_ .. -'� Repair /'Alt Aosorblion Unit '-
$0.00
0
,Inst FAU <100 k BTU
$0.00
0 -
owner:
.AUGUSTINE, ROBERT L TR
0
Address:=
,.,1114 EL CAMINO DR,,-
0
Ventillation System
'
Phone:
Repair/Alt Coolind/Heat''
COSTA MESA, CAS,. /
Zip: 92626
Evaporative Cooler
$0.00
0
Contractor:
$0.00
0
- .. Commercial Incinerator
$0.00
0 ,
,,,Address:
-,
'.0 - - -"_--_
- -'- - - - Domestic Incinerator - -
$0.00
Phone: ,
Refrig Sys >100 k BTU
so.00
Zip: .
"' - Compressors / Absorption Systems
License:
Gas Piping , '�
$0.00
0
Status: ISSUED
Applied: 12/08/2006
Issued: 02/14/2007
ISSUED BY:
SCOPE OF PERMIT
x'360 SF'ADD_ITION.TO EXTEND KITCHEN AND RELOCATE FRONT -ENTRY, REF: B06-02044
�� f MECHANICAL -TO INCLUDE: 1 REPAIR/ALT COOLING/HEAT AND 1 HOOD W/MECH EXHAUST.,
COMMENTS I 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 applicaable,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)
FEE SUMMARY
. -
/-Quantity
Quantity.
:ISSUE FEE r
$23.50-_•_.:
_ .. -'� Repair /'Alt Aosorblion Unit '-
$0.00
0
,Inst FAU <100 k BTU
$0.00
0 -
- - Repair/ Alt Refrigeration Unit
$0.00
0
Inst,FAU >100 k BTU,
$o.0o
0
Ventillation System
$0.00
0
Repair/Alt Coolind/Heat''
$13.70
1
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
so.00
'- 0-
"' - Compressors / Absorption Systems
Gas Piping , '�
$0.00
0
Up to 3 hp / 100 k BTU
$0.00
0
Factory Fireplace
$0.00
o
3 To 15 hp / 500 k BTU
$0.00
'10
Hood w/Mech Exhaust '• <'.
$10.65
1
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'
Appllance�\ $0.00
0
f, � r' Boilers
$0.00
Fire Dampers
0
Up to 3 hp.
$0.00
0
>V•°�
Smoke Dampers +
`` $0 00
0
- 3 To 15 hp'�,
$0.00
0
Inst or Relocata Appl Vent
���,so o0 ^��O
s,+-/,,
-- , -15 to 30 hp
$0.00
0
Air Handlers <-10000cfm�
'$0.00
,,I0
-0 -0
30 to 50 hp _
'Over
$0.00
$0.00
0
0
Air Handlers >-10000cfm� �
$0.00
�- 50 hp' - . - -
Floor Furnace `i-
�• $0 00
.0`�
- : "Other Mechanical Fee
-
Floor or Suspend Heater,
$000
0 '-
��
,_ .`� Investigation Fee; ,
Plan Check -Fee' r • "�"�;.' i `'�
. $o.00
$o.00
Reinspection Fee
30.00
-�
•
1 �,
- / , / -' TOTAL CALCULATED FEES
$47.85
COMMENTS I 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 applicaable,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)
Ah
AMk
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 performance of the
work for which this permit is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carrier and policy number are:
Carder: Policy Number:
(This section need not be eaTiple0cfAlho permit is valued at one hundred dollars ($100) or less.)
1 certify that in &peo n of t e wo for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation to, d agre that it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with ths
Applicant Signature: Date: l
WARNING: FAILURE TO SECURE WOWERS'a4ENSATIM COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TOONE HUNDRED
THOUSAND DOLLARE($100.000). IN ADDITION TO E COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
force and effect. Lic. a Class 4
Contractors Signature; Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this Permit is issued. (Sec. 3097, Civil Code).
Lenders Name: 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).):
Zl__YSs 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, a own the r m EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
C e: T ac clods icon Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors)
li se urs L nt to th Conti ctors License Laws.). d 1 ^ G
I a axe u e ec. Business and Professions Code for this reason: Y
Signature: —
Owner ID verified by driver's li rise. ❑ Yes ❑ No Drivers License No. Expira;
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feat 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, 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 resent or future building Occupant need to file a registration form for acute) hazardous materials.
p p g p g y ❑Ves ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
........................ ................................................. ........................... .................................................................................................. ......................................................................... -............................... ............................ ...................... ..........................
3 Does or will theappplicant or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes [INo
(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 resent) re uired, has Section 25534 of the California Health and Safe Code been full complied with?
P Y q N Y P El Yes ❑ No
................_................_............._plic............_...........................................ildi.._..................................................................................................................................................on....................................................difi................
5 Does or will the oast Air or present or future building occupant require for the work which is the subject c this application apermit 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 LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
_........._..............__.......ofth.,..acil............__..........................._......_._.toi...........-o--u.................................................._..............................................................................................................
6 Will any pan of the facility to be constructetl untler this permit ba 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 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 byCalifornia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
........._.........................................._._............_......._....................................._...... ......................__...............__.........___._._._..................__..__..__....-.........`_..".._...............
8 (II yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CE CA MIFCIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
co re . I ag a to C ply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
ab ve as ed perry r iospectio�oses. I agree not to occupy or allow occupancy of any building authorized by this pe2unt=l final inspection.
62
C-)7
Signature Of Legal Owners) Date
And/Or Authorized Applicant Date
CODE r. INSPECTION TYPE P/E INTITALS CODE INSPECTION TYPE - �UTE INTRIALS
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 Fife Place - 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.PLT)MBING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 1114 EL CAMINO DR
Suite No
Vicinity:
Parcel Nunmbor: 14161216
Applicant:
AUGUSTINE, ROBERT LTR
Address:
1114 EL CAMINO DR
-ter,
.,'License: 000000
.-
COSTA MESAI CA,, '", . - -
Zip:
Owner:
/AUGUSTINE, ROBERT,L T.R--
Address-�
1114 EL CAMINO
�
Phone:
-
it D
SCOPE OF PERMIT
J;
'COSTA MESA, CA '4y
Zip:
r %,,/
Xi
/
Contractor"-�
OWNER -,,BUILDER
,Address::
PLUMBING INCLUDES:
1 DISHWASHER, 1 LANDSCAPE
IRRIGATION, 2
P -TRAPS, AND 2 KITCHEN'
Phone:
ISSUED BY:
714.557.5354, - -_
92626
Status: ISSUED
Applied: 02/14/2007
Issued: 02/14/2007
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
20 6 (6/00)
Zip:
.,'License: 000000
-
it D
SCOPE OF PERMIT
ADDITION t � 380 SF ADDITION
TO.EXTEND KITCHEN AND RELOCATE FRONT ENTRY., REF.: 606-02044 �\
PLUMBING INCLUDES:
1 DISHWASHER, 1 LANDSCAPE
IRRIGATION, 2
P -TRAPS, AND 2 KITCHEN'
,
SINKS.
- FEE SUMMARY
AMT ..
QTY
AMT
2
AMT
QTY
ISSUE FEE- $23.50
Laundry,Tub / Washer
$0.00,.
. 0, ,
Sump Pump
$0.00
0
Backflow irrigation $0.00
0 - Land scapearrigalion
$14.80 ,�
'1 _' �'�
�_ Swimming Pool
$000
0
Backflow Preventer , ,- $0.00
0 .... _. P_Trap
$19.60
2
_ . Trap Primer -
$0.00
0
Bathtub 1 $0.00
0 Pressure Regulator
- -$0.00
0
Urinal
_ $0.00
0
Clarifier System '�`t-, $0.00
0 i Process Piping (per 10 ft)
x$0.00.
0
Vacuum Brkr BkFlow(1-4) -
$0.00
0
Connect (Ice,Soda,etc) ;�. x$0.00
''
0, Receptors
.$0:00"
-0
'Vacuum Brkr Bkflow(5+)
$0,00
0
Dental ;Units- \ , .. $0.00
Ol Septic Tank
$0.00-
0
Wash Basin: >;;
50.00
0
Dishwasher ', ' $9.80
1 Sewer Cap for Demo_
$0.00
0
Wash Basin _
$0.00
0
Drain, Floor ,$0.000
Sewer Conned,:'
- $0.00
0
Waste and Vent System
$0.00
0
Drain, Rainwater" $0.00
0 Sewer Private Line
$0'00
0
Water Closet (Toilet)
$0.00
0
Drain, Roof$o.ov
0- Shower
$0.00''-0
Water Heater/vent -
$0.00
0
Drinking Fountain $0.00Q
O �^-'': ."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 /S0.00
0 ..Sink, Floor .
> $0.00
0
„Water Service
$0.00
0
Gas (1-4outlets),A"/ `/$0.00'�r_
0����Z�.:_C` Sink,kitchen,' -
$19.60'
2
--;,Water Softener -
$0.00
0
Gas (Over 4 outlets)`�� <$O.00 i
�0 �� " Sink, service/mop �-
�'�S'pa:(pnv_ate),��
$0.00
0." ;
�",
OTHER ,'
$0.00
Gas Repipe ' �.���$0:00/ �
.
0,- -,
$0.00'.;
- 0'. -'
". VIOLATION ,
$0.00
-.
Gas Service $0.00'x`'
0 ..-, Spa (public)_ - -
$0.00
0-
- PLAN CHECK
$0.00
Interceptors (Grease, Oil) \$0.00
0 - 1 r - -
-
REINSPECTION
$0.00
0
Interceptors(Sand Auto) $000- `.,,0
In .-`� C
,
TOTAL CALCULATED FEES:
$87.30
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
20 6 (6/00)
n
r --I
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' Componsatlon Insurance carder and policy number are:
Carrier: Policy Number:
(This sec on need not be leled if the permit is valued at one hundred dollars ($100) or less.)
I certify that in th ped m c w for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation IS s of allf a, a ogre that it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with then pro i S.
Applicant Signature: Date: off-
WARNING: FAILURE TO SECURE WORKERS' ENSATION COVERAGE IS UNI -AWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE (5100.000), IN ADDITION TO 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 all!" 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. x Class N
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code),
Lender's Name: Lenders Address:
Signature: Date -
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county.which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he Or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil Penalty of not more than five hundred dollars (s500).):
0--r—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 wit ' ar o mpletion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as o nor o pro am CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code The mr t rs LI rise does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
Iicen a pur an o he ntract is License Laws.).
em xempt der Business and Professions Code for this reason:
Signature: Date: CIS IZV
Owner ID verified by driver's licens ❑ Yes ❑ No Driver's License 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 S, 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 SafOly 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).
___ ......u_.ant............fit...... ....... ....... .........................................
2 Does or will the applicant or present or future building Occupant needto e e registration form for acutely hazardous materials. ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
....................................................... .............................................................................. ................................ .................... .................................................. .... ...................................................... ................. ....................................... .....................
.........
3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 Il an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No
.........................................................................................................................................................................................................................................................................................................
5 Does or will the applicant or present or future building occupant require for the work Which is the subject of this a plication appermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 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 feel from the outer boundaries of a school? ❑ Yes ❑ NO
(If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
......................................_........................_.................._.._..............lity.._...................................................................trol.................................................................................................................._...............lo-e......................
7 a a pation have
the South Coast Air Quality Management is Heal or other air pollution control district n 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? [I 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:
C A O P CE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
c rre I. I ag a Io co ply lh all state laws and dry, ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
a ave esc ed pr arty 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) Date
And/Or Authorized Applicant Date
CODE r. INSPECTION TYPE DATE INTMAIL CODE# INSPECTION TYPE PAIS INTMAUS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing '� ��
2DO Final Re -Root 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
CPTY OF COSTA MESA
p
BUILDING DIVISION
— Unit:
City/State:
Cit
SANTA ANCA
A,,
F77
FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 '• www.d.costa-mesa.ca.us
�•
�Mroxm�
FOR INSPECTIONS CALL: (714) 754-5626
ARCHITECT:
PERMIT NUMBER: BX07-00047
PERMIT TYPE B_MISC
STATUS: ISSUED
Final Site
DATE ISSUED: 07/30/2007
ENGINEER:
ISSUED BY: SOK
JOB ADDRESS: 1114 EL CAMINO DR CM „ - '::Suite/Unit:
Vicinity:
"Primary Occ: -_' Const Type :??
SQ. FT: 0
Valuation :' $500;00
SCOPE OF WORK: REPLACE WINDOW LOCATED IN MASTER.BEDROOM TO.MEET 1997 U.B.C.
EGRESS REQUIREMENTS. HEADER -.WILL
REMAIN THE
SAME.`
$0.00
OWNER: AUGUSTINE. ROBERTi TR
Address:: .1114 EL CAMINO DR Unit
City/State: COSTA MESA, CA
Zip Code: 92626,--. r -
Phone:
- $0100
APPLICANT: STEVE tJANOSIK.
Address: 1621 E ST ANDREW PL '' Unit
City/State: SANTA ANA, CAF.-
Zip Code:. 92705
Phone: 714-259-5120
$0.00
CONTRACTOR: DIAL ONE WINDOW REPLACEMENT -SPECIALISTS: License No. 523043
Address:
1621-E ST ANDREW PC
— Unit:
City/State:
Cit
SANTA ANCA
A,,
r
Zip Code:
92705
r,
Phone . 714-259-5120 .;Cell:
ARCHITECT:
204
-License No:
Phone
Final Site
250
ENGINEER:
License No. ;
Phone
10,
FEE`SUMMARY ~
Building Plan Check
$0.00
Building Permit:
„$23.50 .. -
Electrical Permit:
- $0100
SMIP Residential
$0.00
SMIP Commercial
$0.00
$O.00TOTAL FEES
$23.50
XL
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 X. INSPECTION TYPE
1616 Fixed System Final Fire Prevention
1266
Pool Spa Final
200
Final Re -Roof
201
Final Block/Retaining Wall
202
Final Factory Fire Place
203
Final Sign
204
Final Demolition
DATE INTMALS
CODE#
INSPECTION TYPE
206
Final Mechanical
208
Final Plumbing
210
Final Electrical
212
Final Fire Prevention
220
Final Planning Approval
222
Final Site
250
Final Building/Occupancy
DATE INTMALS
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
pe ormance of the work for which this permit is issued.
);have and will maintain workers' compensation insurance, as required by
`'A 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:
wrier:,
(This sedlon needrrol be wmplefeO Alpe permR 6 velueGaf one hvMredbellars (E100) a lest)
Eolicy.Numbar: --
[] 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 orthwith comply _
Lab r ode, I sh these provisions.
q-30-07
MAppli is ignature - - Date -
WARNING: FAILUR 'O 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.
�—
l.icV# _[rCl ss#—
AD
Comriaoix'sigm re _�� (_Wle
CONSTRUCTION LENDI GENCY:
❑ 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
OWNER -BUILDER DECLARATIONS:
t 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:
305716 (M)7)
Owner hYverifi8tLby drivt ,nse. ❑ 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:
❑ 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 -sits (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
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to file and
certify a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some
exceptions. that a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard temperature and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
hazardous materials equal to or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
temperature and pressure).
3. Does or will the applicant or present or future building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the
Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department,
4. If an RMPP is presently required, has Section 25534 of the California
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require for
the work which is the subject of this 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 rlon-residential building permits).
& 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 distract 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 stale laws and
city ordinances regarding Hazardous Materials and Emissions.
Signature
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury that I have read this application and slate that
the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
the City of Costa Mesa to enter upon the above-described property for
inspection purposes, I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
_ g Lure of Lea (+wnegs) Dale
olw.AWhonz a' plirant IDate, _
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
PLUMBING PERMIT
Job Address: 1114 EL CAMINO DR
Suite No
Vicinity:
Parcel Nunmber: 14161216
Applicant: JOHNSON, NORM
Address: 24707 SAN FERNANDO RD -
Phone: (661)259-7131
SANTA CLARITA, CA : Zip: 91321
Owner: AUGUSTINE, ROBERT L TR,
Address 1114 EL CAMINO DR
Phone:
COSTA MESA, CA Zip: 92626
Contractor: AFFORDABLE WATER HEATERS R PLUMBING
Address: 24707 SAN FERNANDO RD
.SANTA CLARITA, CA
I
Arch / Eng
Address: "
CHANGE OUT WATER HEATER.
Phone: (661)259-7131
Zip: 91321
License: 627368
Phone: - -
Zip:. .
License:
SCOPE OF PERMIT
Status:
ISSUED
Applied:
FEESUMMARY
Issued:
10/29/2002
AMT
QTY
0
AMT
QTY
ISSUE FEE
$23.50
$0.00
Laundry Tub / Washer
$0.00
0
Backflow irrigation
$0.00,.
0
Landscape irrigation
$0:00.
0
Backflow Preventer
$0.00-
10
P -Trap'
$0.00
0
Bathtub
$0.00 -
0 '-'-
' Pressure Regulator
$0.00
0
Clarifier System
$0.00,
0 ,.' -,
Process Piping (per 10 ft)
$0.00
0
Connect (Ice,Soda,etc)
$0.00 --
0- _-,�,�,
Receptors
$0.00
0
Dental Units -
$0.00
0 ^-
Septic Tank
$0.00
6
Dishwasher
$0.00
0
Sewer Cap for Demo
$0.00
0
Drain, Floor
$0.00
0
Sewer Connect
$0.00
0
Drain, Rainwater
$0.00
'0
Sewer Private Line
$0.00
0 -
Drain, Roof
$0.00 .'
0
Shower -
$0.00
0
Drinking Fountain
$0.00 -
0
Sink, bar
$0.00
0
Expansion Tank
$0.00
0
Sink, commercial
$0.00
0'
Gas Earthquake Valve
$0.00
0
Sink, Floor
$0.00
0
Status:
ISSUED
Applied:
10/29/2002
Issued:
10/29/2002
ISSUED BY:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626
2"0 6(f )
AMT
QTY
Sump Pump
$0.00
0
Swimming Pool
$0.00
0
Trap Primer
$0.00
0
Urinal
$0.00
0
Vacuum Brkr Bkflow(1-4)
$0.00
0
Vacuum Brkr Bkflow(5+)
$0.00
0
Wash Basin
$0.00
0
Wash Basin Set
$0.00
0
Waste and Vent System
$0.00
0
Water Closet (Toilet)
$0.00
0
Water Heater / vent
$12.30
1
Water Piping (Inst or Rep.)
$0.00
0
Water Re -pipe
$0.00
0
Water Service
$0.00
0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626
2"0 6(f )
DECLARATIONS ij�
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit Is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carder and policy number are:
Carder: Policy Number:
(This section need not be completed if the permit is valued of one hundred dollars ($100) or less.)
❑ 1 cenity that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that if I should become subject to the workerscompensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provision,s(,n �/
Applicant Signature: U/v r 7 — Date:
. WARNING: FAILURE TO SECURE WORKE S- COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED
THOUSAND DOLLARE (S100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION VOS OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full
force and effect. Lic. a 2 L Class ,# C.36
%Contractors Signature: , Date: % D^ ?
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued, (Sec. 3097, Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her Own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: (L)l i"�'r . Date:
Owner ID verified by ddvere license. ❑ Yee ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - Property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title B, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building Occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
...................................................................................................................... ..................
2 Does or will the
int or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
.............................................................................................................................................................................................................................................................................................................................................................................._........_
3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ NO
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, codification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
._...........................................................................-................................................................................................................................................................................I............................................................................................
P Y q Safety Y P ❑ Yes ❑No
...................
4 If nn RMPP is resent) required, has Section 25534 of the California Health and Sale Code been full complied with?
.................................................................................................................... ildi........................................................................................................................................................................rnit..............................................................difi...............
5 Does or will the applicant u present or future building occupant require for the work which is the subject c this Uplicalion aEertnit for such construction or modification
from the South Coast Air Ouellry Management District or from any other air pollution control district or agency? LJ Yes LJ No
(Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits).
...................................................................................................................................................................................................................................................................................................................
e Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Ves ❑ No
(if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
_ ........................ _..... ..... _..........._............ _................ __.................... ........ _........................................................................................ ........................................................................... _._._..... ................___.......... _.................... _........ _..........
_..
7 If apermit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
B (If yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. I agree not to occupy or allow occupency of any building authorized by this permit until final inspection.
Signatur-910f Legal nods) ,pate2
And/Or Author ed Applicant - ULDate f
CODE E. INSPECTION TYPE 2AH IIfIITALS CODE -S INSPECTION TYPE gdTf jKTMALa
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Root 210 Final Electrical
201 Flnat Btock/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
2D4 Final Demolition 250 Final Building/Occupancy
rj
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address: 1114 EL CAMINO DR
Suite No
Vicinity: NEW ROOM ADDITION
Parcel Nunmber: 14161216
Applicant: AUGUSTINE, ROBERT LTR
Address: 1114 EL CAMINO DR
Phone: (714)557-5354
COSTA MESA, CA Zip: 92626
Owner: AUGUSTINE, ROBERT L TR
Address 1114 EL CAMINO DR
Phone:
COSTA MESA, CA Zip: 92626
Contractor: OWNER -BUILDER
Address:
�.
;i-•. _ Phone:
Zip:
License: 0
SCOPE OF PERMIT
5 LIGHTS, 7 OUTLETS AND 4 SWITCHES FOR NE ROOM ADDITION.
REF:B00-01152
ISSUED BY:
Status:
ISSUED
Applied:
08/08/2000
Issued:
08/08/2000
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
2446-46 (6100)
FEE SUMMARY
Quantity
-
Quantity
ISSUE FEE
$23.50
Temp Dist System / Lighting
$0.00
0
Temp service test
$0.00
Busway /100 It
$0.00
0 '
Res. a/c package
$0.00
Standing Section
$0.00
0
New Res (1-2 units)
$0.00
0
Misc Electrical Equipment
$0.00
0. -
New Res (3+units)
$0.00
0
Transformers up to 1 kva/kw
$0.00
0
Pool / Spa
$0.00
0
.............. to 10 kva/kw
$0.00
-0
Lighting Fixts
$5.50
5
...............:.up to 50 kva/kw
$0.00
0
Recept Outlets
$7.70
7
.................up to 100 kva/kw
$0,00,
0
Switches
$4.40
_ 4
.
..................over 100 kva/kw+`-.-
$0.00
0
Non Res Appl
$0.00
0
Low Voltage Equipment -
" $0.00
0
Res Appl
$0.00
0
Low Volt Wiring System / Ckt
$0.00
, . 0
Service to 200a
$0.00
0
Misc. Conduit -
_
$0.00
0
Service to 1000a
$0.00
0
Misc. Conductor
$0.00
''o ,
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
$q.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
$41.10
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
2446-46 (6100)
Ah
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance 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.)
❑ 1 certify that in the performance of the work for which this permit is issued, 1 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 OOVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE (5100,000), IN ADDITION TO THE OOST 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. x Class a
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade).
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 Iicerised 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).):
'as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or hers el 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 o ye of cam ' n, the owner -builder will have the burden of proving that he or she did not build or improve for purpose Of sale.).
❑ I, as owns of the r rty, am E CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: Th CO
r 'cense w does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license p rt the ontr Ors License Laws.).
❑ 1 am axe de s Business and Professions Code for this reason:
Signature:
Owner ID verified by drivers licen . ❑ Yes ❑ No Driver's License No. Expires:
Verification of Ownership by (typ of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
......................................................................................................ure-......-i-li.....................ar-it.................... ill-...........-ist........................ .................na--Is-?.................................................................
........
......................
2 Does or will the applicant or present or future building Occupant need to file a registration form for acutely hazartlous materials? ❑Ves ❑ No
(Section 25533 of the California Health and Safety Cotle, 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 theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
13 Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
........................................._................... _........... _............... _.................__....... _...... _._........................................................................ ................................._._...................... _............... ........................................... .._.............
_.........._...
4 If en RMPP is presently required, has Section 25534 Of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No
._ ..................... ..._..........__....._............_.............__.............—.................... __........... _... _.... _..................................................................................................... _........................ _.................................................... ._......................... _............ _.
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aRPemit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes L_I No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
.................:......... ......................... ................................................................. ... ....................................................................................................................................................................... .............................. .............. ......................... I .......... I............
8 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 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 ❑ 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 PV LA��,2fl()N OF ENTRY: I certify under penalty of perjury that I have read this application and state that the infomation given is
correct. I agree to o ply ith II dyortlinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described p P for ins es. I agree
=ot to or�upy or allow occupancy of any building authorized by this pemit until final inspection.
C3 a
Signature Of Le t
I Owner(s) Date
And/Or Author ed Applicant Data
CODE P. INSPECTION TYPE PAIS INTITIALS CODE# INSPECTION TYPE PATE jNTMA�
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Root 210 Final Electrical Iz ZZ
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.c6.011-DING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 1114 EL CAMINO DR
Suite:
Vicinity: AT REAR OF HOUSE
Parcel Number: 14161216 Zoning:
Applicant: AUGUSTINE, ROBERT L TR
Address: 1114 EL CAMINO DR
ISSUED BY:
Phone: (714)557-5354
COSTA MESA, CA Zip: 92626
owner: AUGUSTINE, ROBERT LTR
Address 1114 EL CAMINO DR
Phone: (714)557-5354
COSTA MESA, CA Zip: 92626
Contractor: OWNER -BUILDER
Address:
Phone:
Status:
ISSUED
Applied:
08/02/2000
Issued:
08/08/2000
Zip:
License: 0
'
Arch : ROGER -A REYNOLDS
Eng: -
Address: 1365 CAMINITO GABALDON #E
Address: '
Phone:
(619)291-3666 - Phone:
SAN DIEGO, CA
Zip: 92108 License:
License:
SCOPE OF PERMIT
CONSTRUCT NEW 225 SF SINGLE STORY
ADDITION AND 675 SF COVERED PATIO COVER AT REAR OF EXISTING SFD.
FEE SUMMARY
Plan Check: $294.03
Calc Valuation: $30,118.50
Permit: $452.35
Claim Valuation: $0.00
SMIP Res: $3.01
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $749.39
SETBACKS
MAIN STRUCTURE Front 0-0
ACCESSORY Front 0-0
PARKING Existing: o
NOTES:
PLANNING & ZONING.'
Rear 0-0 Left . 0-0 - Right 0-0 ,
Rear 0-0 Left 0-0 Right 0-0
Required: 0 Proposed: 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within -180 days, or if work is suspended or abandoned
for a period of 180 days. "
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626 /
244646 (6/00) /
r
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain workers' Compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
My workers' compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars ($100) or less.)
❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California. and agree that 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 TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is In full
force and effect. Uc. It Class A
Contractors Signature: Dale:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name: Lenders Address:
Signature: Date:
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjec he applicant to a civil penalty of not more than five hundred dollars ($500).):
nI, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, es ow r th.
rty, m EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: a on alcen a Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
livens p u i to actors License Laws.).
❑ am e t u
Date: '� eT
Owner ID verified by drivers licen e. ❑ Yes ❑ No Driver's License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 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 Wil] 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).
.................................................................................................................................................................."i'llle,......................o"n"...........fo"'r.................................._......................-...................'e"s..........................._...._..._.........................._......
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Ves ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
...
.._....................................._.......................................,.....................................................................................................................................................................................................................................................................................................
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 registei acutely hazardous materials with the Fire Department.
............................._.......... ... _...........__..........................._.................................................................................___.__..__—___..._................................................ .............................................................................................
4 II an RMPP
is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No
5 Does or will the applicant or present or future building occupant require for the work which is the subject this a plication aPermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LI No
(Section 65650.2 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
........................................ ............. ................ .................................................... .................................... ..........-.... -................................................................................................................ _.................. _.......................... .._......... _............. _...........
..
6 (If'yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFIC TE CO A I7)Tthal
AND AUTHORO Ai nON OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I gra o co p stat® laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above -de crib prop faction purposes. I a ee not to occupy or allow occupancy of any building authorized by this permit until final inspection.
�i nature Of Legal Owners) Date
And/Or Authorized Applicant Date
CODE If. INSPECTION TYPE 2AIE INiMALS CODE tt INSPECTION TYPE 2M INTMAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site �f
204 Final Demolition 250 Final BuildingrOooupancy 1' v✓
VERIFICATION
,1
A city or county, which is required to give notice pursuant to Section 19830, shall attach to such notice, and,
as a condition precedent to issuing a building permit', require the completion and require the return of, an
owner -builder verification.
Attention Property Owner:
An `owner -builder' building permit has been applied for in your name and bearing your signature.
Please complete and return this information in the envelope provided at your earliest opportunity to avoid
unnecessary delay in processing and issuing your building permit. No building permit will be issued until this
verification is received.
L I personally plan to provide the major labor and materials for construction of the proposed
property improvement. A0'�s E] No
2. 1 (have/have not) 44^WC signed an application for a building permit for
the proposed work.
3. I have contracted with the following person (firm) to provide the proposed construction:
Name
Address City
Phone ( ) Contractor's Lic. No.
4. 1 plan to provide portions of the work, but I have hired the following person to coordinate,
supervise and provide the major work:
Name
Address City
Phone ( ) Contractor's Lic. No.
5. 1 will provide some of the work but I have contracted (hired) the following persons to
provide the work indicated:
Name Address Phone Type of Work
1W0 6 )REV. 95B)
I hereby affirm that I have received a copy of the information set forth in Section 19830 of the State
of California Health and Safety Code and have completed the above information to the best of my personal
knowledge, i -o ance with this State law.
Signed: - ` ' Date: 8-8-(30%
Name: r-ko:me L 4 u Q U- i N or
(Printed or Typed)
C.D.L. # OR S.S. #
For more information call City of Costa Mesa Building Division at (714) 754-5273.
i
104248 (FEV. 898(
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
MECHANICAL PERMIT
Job Address: 1114 EL CAMINO DR
Suite No
Vicinity: NEW ROOM ADDITION
Parcel Number: 14161216
Applicant: AUGUSTINE, ROBERT L TR
Address: 1114 EL CAMINO DR
ISSUED BY:
Phone: (714)557-5354
COSTA MESA, CA Zip: 92626
Owner: AUGUSTINE, ROBERT L TR
Address: 1114 EL CAMINO DR
Phone:
COSTA MESA, CA Zip: 92626
Contractor: OWNER -BUILDER
Address:
.Phone: .
Zip:
License: 0
Arch / Eng
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
1 FACTORY FIREPLACE AND 1 HOOD FOR NEW ROOM ADDITION.
REF:1300-01152
FEE SUMMARY
Status: ISSUED
Applied: 08/08/2000
Issued: 08/08/2000
Quantity
Repair/ Alt Absorbtion Unit
.$0.00
Quantity
ISSUE FEE
$23.50
0
Inst FAU <100 k BTU
$0.00
0
Inst FAU >100 k BTU
$0.00
0
Repair/ Alt Cooling/Heat
$0.00
0
Inst / Rep. Recess Wall Htr
$0.00
0
Refrig Sys <100 k BTU
$0.00
0
Refrig Sys >100 k BTU
$0.00
0
Gas Piping
$0.00
0
Factory Fireplace
$10.65
1
Hood w/Mech Exhaust
$10.65
1
VAV Box
$0.00
0
Vent Fan / Single Duct
$0.00
0
Appliance
$0.00
0
Fire Dampers
$0.00
0
Smoke Dampers
$0.00
0
Inst or Relocate Appl Vent
$0.00
0
Air Handlers < 10000cfm
$0.00
0
Air Handlers> 10000cfm
$0.00
0
Floor Furnace
$0.00
0
Floor or Suspend Heater
$0.00
0
FEE SUMMARY
Status: ISSUED
Applied: 08/08/2000
Issued: 08/08/2000
Quantity
Repair/ Alt Absorbtion Unit
.$0.00
0
_Repair/ Alt Refrigeration Unit
$0.00
0
Ventillation System
$0.00
0
Evapdrative Cooler
$0.00
0
Commercial Incinerator _. -
$0.00
0
Domestic Incinerator'
$0.00
0
Compressors /Absorption Systems
Up to 3 hp ! 100 k BTU -
$0.00
0
3 To 15 hp / 500 k BTU
$0.00
0
15 To 30 hp / 1,000 k BTU
$0.00
0
30 To 50 hp / 1,750 k BTU
$0.00
0
Over 50 hp / Over 1,750 BTU
- $0.00
0
Boilers
Up to 3 hp
$0.00
0
3 To 15 hp
$0.00
0
15 to 30 hp
$0.00
0
30 to 50 hp
$0.00
0
Over 50 hp
$0.00
0
Other Mechanical Fee
Investigation Fee
$0.00
Plan Check Fee
$0.00
Reinspection Fee
$0.00
TOTAL CALCULATED FEES $44.80
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days. -
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626 /
2"646 (SIM)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 37DO of the Labor Code, for the performance of the
work for which this Permit is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carder and policy number are:
Carder: Polity 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 ($100,0Do), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full
force and effect. Lic. a Class a
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lander'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
Cale: 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 -applicant to a civil penalty of not more than five hundred dollars (5500).):
1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within o year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ 1, as owne of h arty, EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: ThZa.nr
t s Lice a Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contracior(s)
license 10 a CO rectors License Laws.).
I am exe
Date:
Owner ID vented by drivers tic se. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Cade).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building Occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Cale 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 atstandard temperature and pressure).
............................ ........................................................ ..__................. .._............. —.._.......... _........... _................................................................................................................ ............................................ .............................................. _.......
_..
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
................................................ ............... ............ ................. _................................ ...... _._....... ........................................................................................................... .............................. ................................ ................................. "'..........................
3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
....._.........._....................................._..... .........._.......... ......_................... ................... ................................................................................................._............ ......................................
4 II an RMPP is presently required, has Section .. of the California Health and Safety Cale been fully complied with? ❑Yes ❑ No
5 Does or will the applicant Air u present or future building occupant require for the work which is the subject of this a plication aPPertnit for such construction or modification
from the South Coast Air Duality Management District or from any other air pollution control district or agency? f� Yes LJ No
(Section 65850.2 of the California Government Code requires that (he requested information be furnished on applications for non-residential building permits).
.............................................. ..................................................... ....................... ..................................................................................._..............._.___................................................. ..................................... ....................... ............................... _.......
8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Ves ❑ No
(If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
.
..........................._.........._............_...........__.........._._..........................._.............................................................................c......rol.....istr...................................................................................._........................._........._........._...........
7 a a permit from the South Coast Air Duality Management District or other air pollution control district or agency is raquiretl for the work which is the sublect of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? El Yes ❑ No
8 (II yes', attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CER7IFlCA OIL1P AN AND AIfTHORVATION OF ENTRY: certify under penalty of perjury that I have read this application and state that the information given is
correct. I e e t c /npl with II state laws and city ordinances relating to building amstruction, and authorize representatives of the City of Costa Mesa to enter upon the
above-desc b d pro a fo spec(ion p`rposes. I gyres not to occupy or allow occupancy of any building authorized by this permit until finalinspection.
�� o O
Si azure Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE E, INSPECTION TYPE gAIE IKITTIA CODE-E INSPEC71ON TYPE
1616 Fixed System Final Fire Prevention 206 Final Mechanical ] p[ 15_ C
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Root 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 1114 EL CAMINO DR
Suite No
Vicinity: ROOM ADDITION
Parcel Nunmber: 14161216
Applicant: AUGUSTINE, ROBERT LTR
Address: 1114 EL CAMINO DR
COSTA MESA, CA
Owner: AUGUSTINE, ROBERT LTR
Address 1114 EL CAMINO DR
COSTA MESA, CA
Contractor: OWNER -BUILDER
Address:
Arch / Eng :
Address:
PLUMBING PERMIT
ISSUED BY:
Phone: (714)557-5354
Zip: 92626
Phone:
Zip: 92626
Status: ISSUED
Applied: 08/08/2000
Issued: 08/08/2000
Phone:
Zip:
License: 0
Phone:
Zip:
License:
SCOPE OF PERMIT
UPTO 4 GAS OUTLETS AND 1 KITCHEN SINK FOR NEW ROOM ADDITION.
RERB00-01152
TOTAL CALCULATED FEES:, .$39.45
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
2446-06(6/00)
FEE SUMMARY-
AMT
QTY
AMT
QTY_
-
AMT
QTY
ISSUE FEE
$2 3.50
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 (Ica,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 / 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)
$6.15
1
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:, .$39.45
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
2446-06(6/00)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit Is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the pertomiance 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 cedity that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: 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 DODARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION WW OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full
force and effect. Lia a Class a
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lander'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
subject the applicant to a civil penalty of not more than five hundred dollars ($500).):
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 appy to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is
sold wit ne year o mpletion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as o nor rope am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code Ira tors U rise Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s)
licen e u ant t the C ntractors License Laws.). eco
❑
lam x pt er s ��
Expires:
Verification of Ownership by ( e of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Glp 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 Pernit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
............................................................... ............................................... -.................................................................... ............................_... —_.._......... ...................................... _.............................................. .............................................
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Ves ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
......................................... _............. _................ __.................. _.............................. _....................................................................... ...................................... .............................. ............... ............................... ......................... .......................................
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 ofthis a plication aggermit for such construction or modificationfrom the South Coast Air Quality Management District or from any other air pollution control district or agency? LJYes 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 pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Ves ❑ No
(if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the Calitomia 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 proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes [:1 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:
CERTIFICATEWyw
AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agreo laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-describn purposes. I agreg not to occupy or allow occupancy of any building authorized by this Permit until final giection.
S_
Sign ure Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE 1, INSPECTION TYPE PAT& INTITIALS CODE1 INSPECTION TYPE 2AH KTITIA
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Rcof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
i 4F CITY OF COSTA MESA f
'A
P4 BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT
� FAR_00476
4 PERMIT PERMIT NUMBER
(714) 7`54-5273 Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address: 1114 EL CAMINO DR
Suite No
Vicinity: _
Parcel Nunmber: 14161216
Applicant: AUGUSTINE, AUDREY
Address:
Phone:
Zip
Owner: AUGUSTINE, ROBERT L TR
Address 1114 EL CAMINO DR ,
Status:
ISSUED
Applied:
1'I2
06/01/1998 alb
Issued:
06/01/1998
Phone: ..
COSTA MESA,CA Zip: 92626
Contractor: THE AUGUSTINE CO INC
Address: 8334 CLAIRMONT MESA BL -
103 - Phone 619 560-4466
SAN DIEGO, CA Zip: X92111
'License: 638749' : 1 '
SCOPE OF PERMIT
UPGRADE ELECTRICAL SERVICE TO A 100 AMP SERVICE.
Quantity
ISSUE FEE
$22.00
Temp service test
$0.00
Res. a/c package
$0.00
New Res (1-2 units)
$0.00
New Res (3+units)
$0.00
Pool / Spa
$0.00
Lighting Fixts
$0.00
Recept Outlets
$0.00
Switches
$0.00
Non Res Appl
$0.00
Res Appl
$0.00
Service to 200a
$27.25
Service to 1000a
$0.00
Service over 1000a
$0.00
Motors to 1 hp
0
Motors to 10hp
$0.00
Motors to 50hp
$0.00
Motors to 1 00h
$0.00
Motors over 100hp
$0.00
Communication drops
$0.00
Sub panel to 200a
$0.00
Pole Light Pkg
$0.00
Sign Circuits
$0.00
Temp Pwr Pole
$0.00
Intermed Pole
$0.00
FEE SUMMARY
"
Quantity
Temp Dist System / Lighting
$0.00
0
Busway /100 ft
$0.00
0
Standing Section
$0.00
0
Misc Electrical Equipment
$0.00
0
Transfooners,up to 1 kva/kw
$0.00
0
.............. _up to kva/kw
$0.00
0
X10
................. up to 50 kva/kw
$0.00
0
................. up to 100 kva/kw
$0.00
0
...._.._.:.... 100 kva/kw
$0.00
0
Low Voltage Equipment
$0.00
0
Low Volt Wiring System / Ckt
$0.00
'� 0
Misc. Conduit
$0.00
- 0
Misc. Conductor
$0.00
0
Circus ( gen or:ride)
$0:00
0
Circus (mech ride or lights)
$0.00
0
- Christmas Tree Stand'
" $0.00
0
• Fireworks Stand _ -
$0.00
, 0
- Other Electrical Fee _
$0.00
,
Investigation Fee
$0.00
Plan Check Fee
$0.00
Reinspection Fee
$0.00
TOTAL CALCULATED; FEES $49.25
COMMENTS / SPECIAL CONDITIONS
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
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) 7545626
DECILARATIONS
WORKERS' COMPENSATION DECLARATION:
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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 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 carver and policy number are:
Cartier: Policy Number.
(This section need no bo'complefed if the pelf valued of one hundred dollars ($100) or less.)
❑ 1 certify that in e p rlomlance of a ork or which this rmlt is issued, I shall not employ any person inanymanner so as to become subject to the workers'
compensation laws of alifom , and agree th t H I ould b come subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply With then pr sions.
Applicant Signature: Date: n
WARNING: FAILURE TO SECURE WORKERS' PENSATION COV GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND IXXIARE.($100,000). IN ADDI ION T E COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
LICENSED CO ACTIS DECLAR N:
I hereby eHirm t7hat am Ii rise
oder r isions f ate 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda, and my license is in full
force and effect. Li # Class #
Contractor's Signalur . Date:,
CONSTRUCTION LENDING AGENCY: 1.1
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for Which this permit is issued. (Sec. 3097, Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ 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 Pr few*ons Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
all
or herself or lhr ugh his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
colt none year of mpletion the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
L7 1, as own r of the pr , am E CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
C e: Th contractors ense La does not pply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors)
li se pu uanI the tractors 'cense La s.).
❑ I am xem I and r so - Business and Professions Cade for this reason:
Signature: Date:
Owner ID verifled by driver's Inse. 11Ye ❑ No Driver's License No. Expires:
nership
Verification of Owby ( of document, Le. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby candy 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, 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 forth 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 o1 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
............................................................................................................................ r'e.p.......l-n—1..........(Ris.......................................enti.......rogr...............0tel.......................aterials)?
3 Does or will the applicant or, present or future building occupant neetl Io prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ No
Rection 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
partment of an RMPP by businesses which are required to register acutely hazardous materials With the Fire Department.
....................................................................................................................................................................................................................................................................................
4 If en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
....................................................................................................................................................................................................................................................................................
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication appermil 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 non-residential building permits).
....................................................................................................................................................................................................................................................................................
8 Will any part of the facility to ba constructed untler 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 reaulred 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? ❑Vas ❑ 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: T1 Date:
C CATE OF COM ANCE AN AUTHOR 'no
OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
co act. agree to compl with) III Ste laws and city o dinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
a e -d scribed pe for i14 actio pu ses. I agr a not to occupy or allow occupancy of any building authorize by this permit until q
l inspection.
Signature Of Legal ner(s) Date
And/Or Authorized Applicant Date
CODE,, INSPECTION TYPE pA¢ INTITAIS CODE JI INSPECTIONTYPE gA¢ ILLS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 ,Final Plumbing
200 Final Re -Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
2"8& V3
L.
co8r)Q Morsa CALIF 92-62-&
?Lo7-
I - -- - - /-... . .
Vb X11106
—)klZ
FROrt : PES E1-97P.IC PHCIHE ND. : 619 287 9622 May. 28 1998 89:49PM PJ,
• ..
T �Y i C.-+ v .J v u L. �-• -
IN
tiev� 21,00A 120/240V `i ph !
Meier Pi! I in D i sir .
li
—E 1'Oi'240v C�.
5,<i';,I,g 100A_SrvlCa
I
I
--.CE 11?icr SGSe KIN
GU'Jr. IrC' I!1 l,L$
C_ "I f} i
Ex70itl.p,A ON,
I -�A ry ice Pone!
L SDA 12C/240V , C: -I
T CFO.- G: -d 5,/SYB�)(0 w _ 45 Imo
Cu _ orad _ RQ4:
C O.:3d C„ ,,!cu Ici tars:
I E. I n q Se r'd i c hI[I,11 «iN_
nvAC' Lcad =5
7;to 1 145 Amps / phase (mG'u)
" ly//q8
eNtulmc: l A l Y LL l.d9 .LN
IFI(NOINN: AUGUSTINE ROB
ADDRESS: 1114 EL C YAM I NO
COSTA MESA,CA
APPL. MAIL MI ADDRESS
ARCHITECTORENGNEER:
StOIL OR ENG.'S ADDRESS:
L TR
92626
UNIT:
UNIT..
Ow,,CTGRSRAME: PRECISION CONSTRUCTION (714)540-8577
CONTNAMITSMMUNO 1115 EL CAMINO DR
ADORE55: COSTA MESA CA uerla 658880
92626 UM.
LICENSED CONTRACTORS DECLARATION: I hereby affirm under ally of perjury that I rn Iceraad under roveions d Chaplet S
(commendp wish Section 7000 d Dininion 3 ol Na Business end na Code, arch my Ik)rnw u in "El
lace end ettact.
Commit
Cmuc.NO, 05938G /L.cuss: b u N 658880 EXP: 04/98
W R BUILDER DECLARATION: 1 hereby affirm under penaly d perjury Chet am ewmq Isom the Cmtrectm Ir the
A:' wing reason (Section ",
W 1.5 Busi ass and Professions Code: Any city r cauMy which npuiies a peen, to Construct, . saloons.
oliah. r raper any streaturo, pMr to M issuance, also roamea the applicant for such pemM to Sb a sgnsd statement that M or she
licensed Pursant to the rowkna of the Contractors License Law [Chegr D (mmmendrp with Section 7000) of DNeion 3 of the
Business end Puyeasi ns Code] or dial M or she is sempt the armed and the have far rc/ vd the aIWM exemption. Am Section
70G1.5 by any applicant Ir a permit subpda the applicanf to a olvd perWry of nd more than Me hurdired dollen
❑ L as awnsr of IM gopeny, or my employees with wages as their sole cempanwlion, will do the work, and the rrucass is n« intended
or offered for sole (Section 701,, Suvneas and Prdssnns Coda: The Confrecton License Lawdos not apply to an owner of ropeny
who Wolds or impress thereon, and who door such work Nmseli or herself or thrrgh he or her can employees, provided that such
improremente are not iru mded or Blend for sale. I. however, the buff, or inpiovennem is sold within pre year of completion, the
owner,W ilder will have the binders of provip M or she did not build or improve for the Wrpoee of sal
❑ I. m mear of the ropany, am exdusively eontmpc i g with licensed contractee M wnstrutl the Project (section 70,e, Business aM
Pmnlynec re Code: TM Command, License Law does the apply to an owwr of property who Wilde or Imws
rthrear
eon ch who
ts fa su
contracch projects oven a contractods) licensed punurd to the Contractors License Lew).
❑ I em exempt under Section: 8. 8 P.C., for this reason:
I do hereby comly that I am awre of and umierstaM the ha uiremaMa of cal/omie deal earl Safety Cada Sections 25505. 35533. end
2553x, std that I «any future Wi1Eip orupant will I will m1 (circle res) need to comply win al stale cods and the ropuiromerds for
apemht«mvWdionrmodif mnlromtMAi u�0�i—Nenegemsnl District. Ra®denlid wnmtueion applications re eumghom drew
provision.
Date: Applk:anf:
WORKER'S COMPENSATION DECLARATION: I hereby ahem under penalty of penury rr of the Moen, dederaliow:
❑ Ihevaendwilerto.a ceMircredcauerih sW;muro iswakra'c«npetuetim.mProvkadf«barSection 37W dtM talwr
code. f. the penomanpe d the nark far wNpn the Inmdl a issaed.
1 here rhe nail maintain worla s' oompenwetun incorvra. as rosined by Section 37M of Me Labor Code, he the performance of IM
work for rection this permit aieesad. Ma w«ken'WOI IT2Msr rww rd policy numhr re: EXPIRES
Carver: J 4 4 1
vdiay Nambr: - 08/01/98
/This section need trot be comPlred / the Permit orb me horml dulMn ISIWf or May)
❑ 1 certify then in Ihe pr omwrce of the work for which Mie pe u , I shell mI empky arty parson in an)' man w so s to
become subject to the worker' crnoonarion laws d C drench, pts Ihel D I ehrdd become, subject lot workers'
npmsaf on prov _ d Se 'm 37W d the Labor Code. shell n cemply vs'th tfaw Naixw.
vn _
Dane: — Apdicrd:%
Ww_ : Fepun b esuro mf thou'ronpetreetlon roverege M unMwl01, and ehnll f co p! en employer ro rIMrW pen Widf end
rhea pe m me Labor Co f., Irevrld ddmfi (Si nays J, M add/tlon b Ms coat of rompenwfbrt Wnupe u pnsvWetl bar In
Section 3705 of tln Labor Cods, Igen( eM efromsy'a Iwe.
CONSTRUCTION LENDING AGENCY: I hereby affirm under w
peny d perNry, e that them a construction bndng atienw'y, for Me
performance d the wolf for which the perm, is .sued (Section 3W7. CN. C).
LENDER'S NAME:
LENDER'S ADDRESS:
I ceddy that I have mad this application and Ade that the above information is canect. I paw to comply enh aft otyrtd ornty ordarences
and state laws raising to Wilding construction ale hereby auth rdre repreaenlrlves of this city to enter upon the above-nnereionatl property
for inspectionpurposes.PATRICIA ADAMS
Dare: 10 —�()n —9v
Oneen-Fle; Canary-Appfcam; rnk-Revenue Gokenrad Aewasor
CITY OF COSTA MESA - BUILDING PERMIT
PERM NO; d u8531
PERMIT NO: B 085314 PLAN CHECK NO: N GOVT: N SUPP: N
CONSTRUCTION TYPE: V -N PERMIT TYPE: SYR PURPOSE: O'iH
JOB DESCRIPTION : T/O ROOF INSTALL OSE PLYWOOD/40YR COMP SQ FT: 7,501
CLAIM VALUE: 7,501.00 CALL -VALUE: 7,501.00 GROUP OCC: A-1 /U-1
COMMENTS: SMOKE DETECTORS REQUIRED
iEiFiF ie yE fi iEif irk tie ib iE iE iE * iE iE if vEif ie iE iEi4 yF iE iFieie it ih sF if x ve of tie if iP iF in if iE iE rE ii i6iE ie it iisr ii 96 iiieiEif iEif iE ie i(ii ri it if if ih ii iF id if x iE ii ii ie is
Z O N I N G R E Q U I R E M E N T S
S E T B A C K S
------------ MAIN BUILDING----------
FRNT: FT IN REAR: FT IN
LEFT: FT IN RIGHT: FT IN
--------- ACCESSORY BUILDING---------
FRNT: FT 1N REAR: FT IN
LEFT: FT IN RGHT: FT 1N
PARKING REQ: PROV: PARCEL: 14161216 ZNE: REFNO:
PLANNING NOTES,
>„
ie iF if iF iF iE ,Fit iF if;E is it iF iE'ie * * * *;E if iE if aft it it it ii it iF;E iE;r;f x iF * iF iE iF if;v it ie i(• iF ie ie * ie;F ii * iF ii it * * iF ih w;r it iE ie iE ie,if• ie iE it ie;<it ie it iF iE
D E V' E>.L, O P M E N I S E R V I C E S R E Q U I R E M E "N Ir-
ZONING APPROVED. BY DATE:
BUILDING APPROVED BY DATE:
APPLICATION ISSUED BY: —_ DATE: i�1 %CAI Q1
iE ip itiF iE iiir iF iP if>t iPif iii(•ic*iF ii ie sb ii se%7F,eai"ie yFiF'iF�F yF3r sF,!>e sF aF%ieia ir+t y�w7e 7a Tex7a seiF iF ie iE ii iF ie ib se ie lF 1F fe 7e ae se ie
LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIPiRES GRADING
PERMIT 137.25 .75
PLAN SMIP i NON -RES
ISSUE FEE
BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE
TOTALS ---- > 138,00 0.00 0.00 138.00 138,00 .00
REVENUE DIVISION TOTALS--> COLLECTED: 138.00 OVER/SHORT: .00
BLD37Pz5 PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK.75
if iE iF ie iF iE 4 iF it ib iF se it iF * iE iF RF * * iF iF #` ie ie * iE iF if ie ii• it ii ii ie iF if if * ii iF ie if * iF iE iF if sF ie iF if ii iF sb iEiEiE iEiF iF iF iF ie iF iF iE ih iEib iF iE fi iE iii' iE ii� if
I N D I V I D U A L F E E 8 R H A K D O W N
TYPE QTY D E S C R I P T I O N UNIT COST 'iOiAL COST
SFR 7501 REROOF BY VALUE RESIDENTIAL NOZONE 1,00 7,501,00
END OF FEES
18-28-1997/18:43 R8/f138.88
RCPT8:81-8814189
PERMIT:085314
I
CONSTRUCTION AND PLANNING
?� &SPA
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
•,
j3.-Electrical Conduit- Utility-Urtdrgrnd.
54.
Forms
•�4•.-Electrical ConduiYUgdrgrnd.
55.
Electrical Bonding
_
5}_Steel Reinforcement-
56.
Rough Plumbing & Pressure Test
6iElectrical LIFER Grrjd.
.57.
APPROVALTO COVER-GUNITE
r�
:.
7:
Footings -r
- -
58.
Electrical Cond,,W,-Undrgrnd.
r
8!
Foundation i., �-
59.
Gas Pipe, ❑ Undrgrnd_ Test
Water Pipe-Und'rgrnd. ,
60.
Backwash Linef-„P-Trap, u 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 .- q
-
!
65.
Electrical-Final -
15.
Rough Electrical-Conduit
66.
Solar System-Final r
-
16.
Rough Electric Wiri-4
_
67.
Fencing & Access,Apprdval
17.
Rough Wiring Sign
"68.
APPROVED FOR' PLASTERING
18.
Rough Electri Cal-T Bar Ceili g
69.
POO 1_4A SYST MS FINAL
19.
Rough Heating &Air Conditioning`
FIRE DEPT. REQUIREMENT
_
APP$OV,A&. Permit # °�_
20.?Rough FactoF{replace y'� ''
s 'D
y ; e 1-1
21.
-ducts, in:Strticture ;. I ••
-,S:
K -S
O 4 '1
70!-Undergrougd I3 dro
C
l
A
22..Ducn,
Ventilating
71.
Prod 'n�'r' , L~i Oil
_ • , J .
7
.4 •:7
•� r-++ S
utt-7ip�ngas
23.
-Gas.a ipe-Rot h &*Vest
M ^'
? -D t .y
72.
Undergiouhd Ffuctw
24.
%Roof Fri fning' z' ;
'" !�
� K
73.
Undergrjid•Sto aIle;-Yan� O Gas 0-00
r
25.
Roof,Sh€sthing ,-j t' �;
/Q
�f
:
74Y ,Overhead Hydra•
26.
T-83r Ceiling (Svucturall & mw] coat
r S
-
��e
75.,
br r�iCal i
YCh
rr �
K •� �+
27.:Frameand
FI shi , -
a '?9. � •z r
r'
.�{ D K
76.
ad -L'
Dry StadpiPe-In c _V
• 28.
Laitung&Sitling��
FIXED�YSTEf�FINA�t
•�
�
29.
Insulation+.J <-.
_
-
_
78
K '� T:. FIRE PREY. FINAL •
'A
' 30.
Orywall'NailmgfJ•SALT.P
DERT.-FtEQUIR�EMENT
31.
Plaster Biown,Coas:5 -,
e
I
�r,
74.FINAL!MPEC-50N
32.�Electri
MeteF;Final'
".'v
�K
80
FOOD CERTI IC'ATE fSS.UED
.t
33.'Vind4
Ele6tric-, -
r
i
�K•
Notes: •'71*1 _ _
•L'::]
i 34.'FinaLHe2ting=&
AirC3nditioni0'ga
35.
Final'Gas*Pip0,-Test,'
•,
r ,.. I
t
' _=' ,x
'„r
36.
Hood orCanoPY r ' '• ''-
K •'
I
E
'� = •' -
-`
37.
fina).Factory Fireplace
• 38.
FinaDPlumbing t' i�
'Y I
I'.-"=�'
,g'
'
--
+
'k '
1
39.
Wat2r Service-Final
• 40.
Gas Service. Final
- 41.
Solar Domes6b-Findl
D,
ic
i
K
to
42.
Backflow%Preventer a. _c
✓ '
- - -
J
Y.
• l./
-43.
Backflow Irrig48 tion K ;. S
F
M1
"
-'
U N
,
1
"44.
Landscape Irrigation SystemL1^+ _�
7z
I"
'z
v
'v ^ "• .4 _ "v
o
-4 5.x
A tewation`
� W 1
- ^'
"" '1'i
_
;a6.
Handicap.Regolatiogs
s
K ..
- 7 7 S
.•.
•`
47.
FINAL STRUCTURE & BUILDING
n
48.
FINAL PLANNING;
I,
:• c r ••
.
AS.
Electric Release to Edison
-•
X50.
Gas Release to Southern California Gas
Co
i i
A - -�- -
•-+
7 �� , F -
-
51.
CERTIFICATE OF OCCUPANCY
No.
Date
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations
PERMIT N0. 'TRACT NO. - LOT NO. ;BL I
TRUCTION PERMIT' i15'q I Awaho v
icent's`Mailing Address' ` - TYPE OF CONSTRUCTION 'NEW ADD ' •ALTERATION REPAIR?.
act Address i P=i'• j .L (A/�•IINC i 2) P--! ElN❑ OONVERSIO�DEMOLISH ❑_OTHER I _ •4�3� /��/U 1 "'
nor Name' ^e N�?•'A(A� M"-
Phone DESCRIpT10NYOF WORK - _ I ;'.
` - 1 G REGULATIONS;,'
I
FA
ress, '. I�•1�� L C.AMIN'A,1 `•. I I i 'TYPE OF PERMIT i - -+,,
_ t - GRADING F NDATION STRUCTURAL •< A. P. gW: _ ZONE 1
h/Eng I License No.' - I ❑TENANT ELECT LUMBING ❑'MECHANICAL ' !C- , '° i '^BUILDINGS ,_ ( l� i I
- .. I-P,LNG. REF Hk-
ress'"� r I " I I j ❑•'ETHER ' _ t i•" - l TO BUILDING_ t
tractors Nam' •� i S+Fl ! �hgne�17 �0 ` PROJECT DESCRIPTION SO FT.I I OCCUPANCY PROPERTY -INE I - ;,,REAR YARD (TO P/U 1 e r
i "'•I 1 ' iK.P• ! 1 1 .'CON ST TYPE •• h I I VALUATION 1 I .LEFT SIDE YARD RIGHTSIDE YARD + I. ! 1
tet(mailing) = ' S4 1 J� N'41 -h GN Lp , $ n I i ''PKC. SPACEREO.?rPROVIDED '' I Llw rIj!:UI__20NJ= GRADING CU.VDS. ACRE$ '^ 1 C ;'r-5ense No. __
LICENSii6CONTRACTOR DECLARATION i' i ', I Remarks: - i f I I ?' •STREET WIDTH ' I. •PARK FEE $ I 1 '-
1-hereDyiafikr n that -Cam licensed under provisions of Charter (commencing ' ' r I
with section 7000) 07 Division 3 of the Business and Professions Code, 5n0 ! i•'SPECIAL CONDITIONS:
rriy 11<ense�ls In full force and'effect. I rYr/ -- ,-
License Class } �/ S - i i License N0 PLUMBING :) ! i 1 ! 1 i 1 ( i ' f • 1 �. i
'late •� 7 I Signature k • i ' S - f ,
�• i -Bar Sink ; 1 Sewer CaP ' I ! [ ; : ELECTRICAL
DRKERS' COMPENSATION DECLARATION } I . i I -
.iereby affirm that 1 have a certificate of consent to self -Insure or a certificate ' Automatic Washer' I (Meter ❑Over 100 amps I ! '
Backflow.Preventer- _Sewer Connection''_. �, .i f ,
of`Workers' Compensation Insurance):"or'a certlfietll copy f-, (Section - - "�" - r. ,
3800, Lab. C.) I t , ' t ! - - - } ,- • Construction Pole, `j I ISub Panel -
39 / I I P/ > f Backflow Irrigation Solar_ Coltecto_rs_ 1 I- I I T i
Policy'No. Company T_ '' ,. I Cooking Unit 1 ; , (- - -Sub Pole
eCertified cODY IS hereby furnished. 1 i ,1/ , {{ ! Bathtubs I _ ,- Solar Piping t r
Certified Copy Is filed with the'city, Buil 1 g D sion.yyr i I ' 1 t I - Dishwasher j ' i' t !Motors 00-1 HP ❑iX-B t
Dates 'a`5' 'b' i - Applicant'• Clarifiers Soar Tank I
-EXEMPTION' FROM WORKERS';CO MP SATION'DECL--ARATION'!-;""I' -'-Dishwasher ' Swimming POOI W/$Dd - Dryers -❑Gas? -❑Electrics, );" r-•Inc:Solar*❑9,15 Hip "❑16-15+ ,
(Thissection need not be <omDletetl if the permit is for, One hundred ($100) or I I — I I -
less)- . - - ,J S r I ' 1 ' -i ` Drinkin Fountains' r i Urinal i 1 Fan; '.;;!}, 'I. ,i )Microwave
I certify that in the performance Of the work forlwhich this permit is issued 1 I r 9 _ ,
shale not. employany person In any manner so as to become subject. to the , - -.. _ F.A.U. i - j +Pole Li ht
Work Compensation) Laws of California.. { i i Floor Diainsi j i Water Goset{ - f' ?_� + I { I g 1 i i
Data' Signature ' - I ,R i
NOTICE: If, afte[.rnaking this declaration, you should become subject to„the - �. Floor Sinks } _ _ _r _ i Water Heater _ _ .i , ,DO Fixtur¢s.; -�f" i ange ' ( i 1
Workers'- Compensation provisions of the Labor, 'Code, you must forthwith.' - --�' u' '1 t
Comply !with] such rprovisionsi or "this:'permlt shall be Ideemed• revoked} L Gas Service `Outlets' •Water $¢rnce ' I� Device Boxes $ignl '
' CONSTRUCTION- LENDING'!AGENCY�: i . - I •^ • I -.f { _ ( L i- { I .• ' -d,:• - r' ¢ j
i 1 s a Outlets i
1 hereby affirm that there is a'constructlon lending agency for ths'pperformance t Interoeptoro 1 - _ I I ! Standing Sections , i '
of the (work for which 4 this. permit ['Is Iissued • (Section '•3097. Civ. C) I -' `" k - 1 '
Lenders Names f i -' `> f r i - tr ` -• ' ' ' } 1 Kitchen Smk' +r .t t I _ ,- - i �: Switches ; i ! +Trash Compactor
Lenders Aderess1 ' _ u' 1 i i - - - + , - : Garlia eDis oral
OWNER BUILDER DECLARATION a ..✓ f m 1 Lavatdries i Ii ! I _ s , y ! '. . ( .;(` 9 P I + 1 ! r
I herebwaiffirm ythat I am.exeinpt:from the'Contractor's'License Law for the - - ,.y Generaror ❑Oi5 KW ❑5-15 KW
following reason'(Section-7031:5 Business and -Professional Code:'Any city or, 1 { P Trap• I i i ) ,.(. ; j �'
,county which requires a permit;to construct, alter Improve; demolish"or.repair } _ _ ;"{ I ,I . i Trarisfornier ❑ 15.50 KW ( i • I I
any stru<ture` prior to Its issuance,. also req ulres the.applicantforsuth permit Roof, Draih`s' ' I '�. ; ,j f - i f ;. ;1 : 1
,file a signed statement that he/she is licensed pursuant to the, provisions of r r^ ❑SU+ KW ' I I 1 !
'"•`; Contractor's' License Caw,(Chapter,9 (commencinglwithISection 7000) of - '� 1 ° 1 j r'.-<- , '-• t( I f I 1 . ,Reinspection Fee
<Islon ;T -of the •Business-antl Professions Code :Or; that. he/she;is exempt $hOW¢re ) j 1 1 Reinspection Fae ,$1s- 1 , 1 ' ' ' I
"a`reirom_antl the; basis for the alleged exemption. Any ,violation of, Section -� - - " _ ' ' _ -' Meter ❑up to'100 amp, i 1 ; : I tIssu9 Fee f I $ 3 �'
7031`.5 PYK any aDDlitant tor; a. permit-sublects,the ,applicant civil '` i i' - , �• ° I I _ '-11 .+ !
.'�enalty of not more than five hundretl dollars ($500).: f j �. ( i' ! i Service Sink •;, ) c? i I Issue Fee I I I 'Y? 3 Zon`ng Approved By ' ' ! 1 `1 Date'
I,.aslowner of; the,propierty'or[my 4mployee9•with wagestas their sole 1 '
compensation wllhdo the work, and the structure Is not Intended or offered a I ` , Tin I r_- ,MECHANICAL' ( 1 ) 1 Appliotion Approved By I i �)�
for sale I(Sec{ion 7044, Business and, Professional Cotler. Thai Contractor's - - } i , O,� ' I + '
License Law does not apply to an owner Of a Property;who builds or improves Boiler ' - i Refrigeration System ! r:i ,1 a; 9• i
thereon,�ano ;who ;does, such work'. himself/herself or through his or her own - `i : I ! I 1 y • r Application Issued By - ' ' Date
employees, provided that such improvements are. not Intended or offered ,Tor • 1
UP 100,000 BTU Q100,000 BTU'
sale. If however, the building or improvement is sold within one year of com- Duct" Under Ground ' .; , 1 , (� i I. : I • } SUMMARY OF FEES
pletion, the ownerlwill have ,the burden of proving he/she did not build or im. 1 - - I ! 'r {
1+ lova for the purpose of sale). 1 I ? i I ! 1 Duct Structural { i'j j System Repair/Alteration ; "'BUILDING PERMIT $ 9 i I SMTP e' $
Ll I, as owner of the property, am exclusively contracting. with. l iceAed con- 1 - 1 I 'I O I
tractors to construct the project (Section 7044, Rosiness and Professions Code: I I Duct -Ventilating i _ ' { ! _ ; iPLAN CHECK, $ PERMIT
• The Contractor's -License -Law- Law-not•apply"to'an owner•of-propertywho' - !G0SSUANCFy
builds or Improves thereon, antl who contracts for such projects with aeon- I Exhaust System ❑ Multiple ❑+ i I I i ! .PLUMBING $ i , I t
tractor(:) license pursuant to the Contractor's License Law): s 'PLAN CHECK 111 $ 1 GRADING 1 $ '
❑, ham exempt un'der Sectlo.n } B. & P. C. for this reason I Fippl/Fact. Rit. ICBO # I �, i '
7 a t i I I , + I i I , I 1 "
ELECTRICAL $ '� I
Date i J ' t Owner ! : ! ' " f H',ating'System & Ducting I 1
S 1 ! I MICROFILM 1$ j
_hereby certity�[hat I-have•re; this application; antl state�tliat ttie above - ❑4100, 000, BTU.Q100,000 BT' t+ ,PLAN CHECK - $ r
information is correct. I agree to comply with all city and county ordinances • -`�_ '"- Y '�7 - "' `•i"� i ; I , TOTA LrF EE, $.) 1 1
antl,'state laws relating to build g co hereby hereby authorize revre-., 1 Hood or T e I Q ( i ;MECHANICAL $ -
sen tatives of i this -city, to enter upon the above-mentioned property .for{ Cano ' yP 1 f S I Reinspection Fee, ) $15 "'PLAN CHECKt $ i LESS
In" Purposes, )T e 11 ❑ - { i i s. $ s 1 )
Signature 1 'iL�: Date `�--�� i { ! } ? '1 ADVANCED PC -
On "' Is' License or15 V,c ' t ' + Registers I S Isstue Fee ? f ' "i$ 9 1 + ,i FINAL FEE) ; $ )� C�
CMF 0865-46'iev: 12 82"'Wfilter Bulldin `Canar Plnk='Accounting;Goldenrod -'Assessor-" -_..
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. Electrical Service or Pole ' y
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11: Property Sewer Lin"e &. House Conn{ection
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CITY OF COSTA MESA
BUILDING DMSION
DEVELOPMENT SERVICES DEPARTMENT
PERMIT PERMIT NUMBER
10 898-01808
(714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 1114 EL CAMINO DR Status: ISSUED W
Suite: Applied: 10/07/1998
Vicinity: Issued: 10/07/1998
Parcel Nunmber: 14161216 Zoning:
Applicant: AUGUSTINE, ROBERT LTR
Address: 1114 EL CAMINO DR
'Phone:
COSTA MESA,CA Zip: 92626
SMTP Res.
. $0.00
SMIP Com:
Owner:
AUGUSTINE, ROBERT L TR
$0.00
Address
1114 EL CAMINO DR
Total:'
$164.59
Phone:
COSTAMESA;CA Zi 92626 - - "
_
Contractor:
" ' =" <
,
Address
j
Phone:
Zip
License:-
Arch Eng
" Address:
"Phone:A.
Zip
License:
SCOPE OF PERMIT
iCONSTRUCT 60 LF ALONG LT SIDE PL; 72 LF ALONG REAR PL; 74 LF ALONG RT SIDE PL OF 6'
`
HIGH BLOCK WALL FOR ATOTAL OF 206LIN. FT. ALL BUILT INSIDE.THE PROPERTY LINE. NO'
WALL AGREEMENT. REQUIRED UNLESS INSPECTOR STATES WALL IS ON P/L A SURVEY OF THE.
.PARTY
LOT LINE WILL BE REQUIRED IF THE INSPECTOR STATES THE WALL IS ON THE P/L.
FEE SUMMARY
Plan Check:
$64.84 Calc Valuation:
$4,12000
1, Permit:
$99.75 - __ Claim Valuation:
$0.00
SMTP Res.
. $0.00
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00'
Total:'
$164.59
SETBACKS
MAIN STRUCTURE Front 0-0
ACCESSORY Front 0-0
PARKING
NOTES:
Existing: 0
Rear 0-0
Rear 0-0
Required: 0
0
PLANNING'& ZONING
Left . 0-0
Left 0-0
Proposed: 0
Right - 0-0
Right 0-0
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned
for a period of 180 days. ,
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
DECLARATIONS
WORKERS' COMPENSATION DECLARATION: "
I hereby attinn under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work fol whipl.,r permit is issued.
My workers' compensation Insurance carrier and Policy number are:
Carder: Policy Number:
(7771s sect/on need not be completed /f the permit is valued at one hundred dollars ($ IDO) or less.)
❑ I cortify, that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that it I should became 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 Profeselons Code, and my license is in full
force and effect. Lic. # Class #
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or Improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose at 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 cinvers license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Thle 8, California Administrative Code).
❑ As owner -builder, 1 will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
....................................................................................................................................................................................................................................................................................
2 Does or will the applicant or present or future builtling ocoupant 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 fime 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 u present or future building occupant require for the work which is the subject of this a plication apermit for such construction or motliflcatlon
from the South Coast Air Oualiry Management Distract or from any other err pollution control tlistnct or agency? N Yes ❑ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building Permits).
...............................................................................................................................................................................................................................................................................
6 WIII any part of the leclliry to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ 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 relulred 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. [3Yes ❑ No
....................................................................................................................................................................................................................................................................................
6 (If yes-, attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I cartily 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 Emiss ons.
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) Date
And/Or Authorized Applicant Date
CODE /. INSPECTION TYPE Qeg ItQll)ALS CODE r INSPECTIONTYPE 2A19 ILiiITIA�
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Root 210 Final Electrical
201 Final Block/Retaining Well / - p 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolitton 250 Final Buili ing/Occupancy
2446-46
_* :� 202 0
`COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 91y COSTA MESA, CALIFORNIA
For Applicant to Fill In Completely
TYPE OR PRINT
COSTA MESA. CALIFORNIA
MAIL 3800 E. Coast Hi.
MAILADDRESS
as
I Y Q71 I 20.
—
SETBACK LINE FROM
CENTER OP 6TREET ),61 REAR
SIDEYARDI LEFT 51
RIGHT
DESCRIPTION OF WORK
NEW
X
ALTERATION
DATE RECEI ED
1
ADD
REPAIR
ADDRESS
MOVING
ZONE TYPE GROUP - r
DEM
SZIEDINto lx5011G11 RNO. OF OOMS 6 f
EXTERIOR WALL Wood (`_ ROOF _ La
H USE OF
u
1 HEREBY ACKNOWLEOGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COM.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
BUILDING CONSTRUCTION.
SIGNATURE OFM„n,._
M AUTHORIZED
FEE RECEIVED
PUkP;LICANuFINaFa 'PERMI
T
C I TFOR7 P fft§T111sb1 F4 ly
RECEIPT NO.
- PERMIT NO.
qn9 in
RECE;rY
DATE RECEI ED
1
DATE 18BUED
BUILDING
ADDRESS
FIRE
ZONE TYPE GROUP - r
APPROVED
BY DATE
ZONING
ZONE
NO. OR
USE OR NEW
R -1
PLANe 2
BUILDIND W att ar
LEGAL
Lot 7 Tract 5023
DESCRIPTION
A. P. NO. none
NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
SO" TO SIDE S REAR P. L.
EAVES
ALLOWED (U. B. C. REQUIREMENT)
YARDSAPPROVED
YARDSAPPROVED
MAIN BUILDING
ACCESSORY BUILDING
(FROM C/L STREET)
FRONT FT.
FT.
R. SIDE FT.
FT.
L. SIDE FT.
FT.
II
REAR FT.
FT.
DISTANCE BET.
BET. MAIN 8
MAIN BLDGS.
ACCESS. BLDGB.
VAR.#
DATE
C.U.P.#
APPROVED
APPROVED
BY
TE
P
F
Garage 1160 S.F.
SO. FT.
THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
VALUATION
'
PERMIT FEE $
g
g/
LA CHECK
^
$ 1],WL58G0
TOTAL FEE
A,
26485
COSTA MESA BUILDINCT-SAFETY DEPARTMENT
P.O. BOX 130 COSTA MESA, CALIFORNIA 92625
For Applicant to Fill In Completely
TYPE OR PRINT
COSTA MESA. CALIFORNIA
A..
c
LIC.TNO. o2 a7 (O J Nr. 530-332 6
nvE» ;<� % 1 YO^�C^Y G..
nT
SETBACK
DESCRIPTION OF WORK
BUILDING y /0 C_ /� RNO. or
OOMS
SIZE A /f(f ..G I'
EXTERIOR WALL I ROOF
I
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPL=TION
AND STATE THAT THE ABOVE IB CORRECT AND AGREE TO COM.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS RlOY1J1TING
BUILDING CONSTRUCTION. n
KMCAFMFLIAIIIIIIE
AUTHORIZED AGENT
DEC 28-66 00 946 7*****3.00
APPLICATION FOR PERMIT
BUILDING
For Office Use Only
nEenrr
,I
55
R[CE T
- M RECEIva
DAT rig UK
�Z
.2 £f/
j 2 $'
1 ♦ //
BUILDING �/
ADDRESS .I
/
FIRE-1�
ZONE GROUP V
PROVED �/
my DATE Z ZO
` ZONING VC��
ZO [
NO.OF
Puns
USE OF MR
BUILDING -.�F
(
}�S
LEGAL ZPA T
5 z:?
DESCRIPTION C
A. P. NO. / 7—
NOTE: NO [AVE OVERHANG SHALL BE LESS THAN
NOTE;
SO' TO SIDE S REAR P. L-
EAVES
ALLOWED (U.. B.C. REQUIREMENT)
YARDS APPROVED
YARDS APPROVED
MAIN BUILDING
ACCESSORY BUILDING
.(FROM C/L STREET)
PRONT
FT.
R.2109 Orr. -
FT.
I
L. SI 'J FT.
REAR FT.
FT.
DISTANCE BR.
BET. MAIN e
MAIN BLD
ACCESS. SLOGS.
VAR.*
DATE
C.U.P.
APPROVED
APPIT OY
O/
BT
DATE a -O
090 SO. PT.
THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
VALUATION
PERMIT FEE
s N CHECK
TOTAL FEE