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HomeMy WebLinkAbout1120 EL CAMINO DR - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 1120 EL CAMINO DR Status: ISSUED Suite No Applied: 11/30/2000 Issued: 11/30/2000 Vicinity: Parcel Nunmber: 14161215 ISSUED BY: Applicant: DEFINA, WILLIAM Address: Phone: 949-6504905 Zip: owner: STRATTON, KELLIE J Address 1120 EL CAM] NO Phone: COSTA MESA, CA Zip: 92626 Contractor: Address: Arch / Eng : Address: Phone: Zip: License: Phone: Zip: License: SCOPE OF PERMIT REPAIR WATER LINE. FIELD INSPECTOR WILL DETERMINE IF ADDITIONAL PLUMBING FIXTURES REQUIRE PERMITTING, QTY FEE SUMMARY AMT ISSUE FEE $23.50 Backflow irrigation $0.00 Backflow Preventer $0.00 Bathtub $0.00 Clarifier System $0.00 Connect (Ice,Soda,etc) $0.00 Dental Units $0.00 Dishwasher $0.00 Drain, Floor $0.00 Drain, Rainwater $0.00 Drain, Roof $0.00 Drinking Fountain $0.00 Expansion Tank $0.00 Gas Earthquake Valve $0.00 Gas (1-4 outlets) $0.00 Gas (Over 4 outlets) $0.00 Gas Repipe $0.00 Gas Service $0.00 Interceptors (Grease, Oil) $0.00 Interceptors (Sand Auto ) $0.00 QTY FEE SUMMARY AMT QTY AMT QTY Laundry Tub / Washer $0.00 0 Sump Pump $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 P -Trap $0.00 0 Trap Primer $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(14) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $0.00 0 Shower $0.00 0 Water Heater / vent $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $9.80 1 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Spa (private) $0.00 0 VIOLATION $0.00 Spa (public) $0.00 0 PLAN CHECK $0.00 REINSPECTION $0.00 0 COMMENTS / SPECIAL CONDITIONS TOTAL CALCULATED FEES: $33.30 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 2446-46 (6=) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain it comuof consent to salt-Insure for workers' compensation, as provided for by section 3700 of the Labor Cotle, for the performance of the work for which this permit i5 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: 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 CML 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 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 Cade, and my license is In full force and effect. Uc. # Class # 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).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ 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 6, 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 Cade 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 a plication apennit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes Lj No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................... .................................... .......................-................. ........................................................................................................................................... ............................................................ ....................._..................................................... e Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (It Tres', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........._........................... _.......... _........ _........ .... _.................................. _............ __..... ............................................................ .... ...... ........ .... ............................. _...................... __............. ..._.............. _.................... _............ _.......... _............. _. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and . Safety Code Section 42303 been made? ❑ Yes ❑ No .... .........__........._._........._........_........__........._.................. ....... ................. __...._.............................................................................................................................................................................................................................................. 8 (I1 yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 4 1 a re Of Legal er(s) I 30� jjate CAn Or Authorized Applicant I Date i CODE t. INSPECTION TYPE 2&U INiIDA6$ CODES INSPECTION TYPE 2&M INTIT1k� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing -1 S - 2DO 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 DECLARATION OF AUTHORITY FOR AGENTS OF PROPERTY OWNER TO APPLY FOR PERMITS &dg. Permit# - V� This Permit # E $test Address: 1 14 �� ` M 1 IJ O AP Number: 1. 1(we), ./ r // � i 'f'�_ declare that I am the Owner of Title of the above referenced real propmty, and that I (we) hereby authorize: Name: W \ Li- -� Vi' � �` '� ctiS> Telephone Number. (ccy') Street Address: City- � 1 . to obtain permits In my behalf, as ownerfbuilder, for at the above referenced property. State: C. V11 zip: 1.'1-.i )-1 2- Should any parson become an employee engaged in the improvement of the property, I (we) shall immediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa Mesa, as required by State of California laws. 3. As ownedbuilder in W. I understand and accept that my responsibilities do not transfer to any other person, company or corporation. 4. 1 agree to Indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or Personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa. 5. 1 declare under the penalty of perjuryry1that the foregoing is true and correct, Ewa uted this -2)0 day of N t ©V-�.i�"�-1!I-P1`� 20 a , at/ ��Ti �` P� �G , Cafifomia. Print IN Signal Data: Note: This autlareadon does riot grant outhorbow to perform the work as amw, A solely provides for Gmitad paw of atlurney to seare this pemtlt in any behalf. �t�.ru M TOTPL P.03 n `'+ CITY OF COSTA M - /�0" zrL C147%itlL� AI. Building DEPARTMENT Address OF Contractor ('TAi1A�i� l�iz-eyE - Address Permit Date .�(, LNumber �'/O`t-�f�,-Issued BU L NG SAFETY Registee' ty Building inspector Cer 1 of Compliance 96e Date.of this Certificate To the Director of Building Safety: I hereby certify that the following portions of work on the buildings at the above address which required continuous inspection and which I was employed to inspect, were inspected by me and comply with the provisions of the Building Code applicable thereto. - 1) Concrete---- 3) Welding 5) Special Cases 2) Masonry 4) Reinforced Gypsum Swimming Pool Size /& Gunite 1� Hand Pack Sacks Cement A-/ Tons of Sand Approximate % of water in aggregate This report covers work completed during week ending? ' P — r rOR Address Laboratory '+-iG Telephone 4:'7 7-1.,/..25 rl / 1.. Form BU 61�'; ��f/f/( C?•�', �. �0zo9 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 317 COSTA MESA, CALIFORNIA For Applicant to Fill In Completely TYPE OR PRINT B BUILDING ® STATE COSTA MESA. CALIFORNIA Same as above. 43_A-SB-1rTio br OFLOT (2J- x USE OF EXISTING BLDG. SETBACK LINE FROM NO. OP BLDG NOW OH LOT Sone \R YARD 2 81101 HT rii DESCRIPTION OF WORK TEMALMIMMM 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IB CORRECT AND AGREE TO COM. PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUCTION. SIGNATUREOF ,�{{G..�� a fi Com a PERMITTEE ;i by • �u c t �� AUTHORIZEDAGENT -17 ( LE RECEIVED JUL 251987 APPLICATION FSR PERMIT FIN ?N(JUIWING CII rFe1F QM0044 Anly RHCHIPT NO. �yjiBj A LJD/SdI REC8IV�BY 1�68UED D 6RBC81V8G D I66UEDD 6RBCBIVBD _ 2 4 1961 BUILDING ADDRESS FIRE V ZONE TYPE GROU APPROVED BY DATE ZONING ZONENO.OF UBEOFNEW R-1 PLANS BDILDINOw att gar. I LEGAL 6 DESCRIPTION Iot Tract 02 A. P. NO. none NOTE: NO EAVE OVERHANG SHALL BE LESS THAN 80" TO SIDE 9 REAR P. L. EAVES ALLOWED (U. S. C. REQUIREMENT) YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (FROM C/L STREET) FR NT CALFT. FT. R. SIDE FT. FT. L. SIDE FT. FT. REAR FT. 10 FT. DISTANCE BET. BET. MAIN 3 MAIN BLD S. ' ACCESS. SLOGS. VAR.* DATE C.U.P.# APPROVED APPROVED 7 D R Garage 483 5.11 SO. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. VALUATION PERMIT FEE $ $ 207288.00 C70 PLANCHECK S C%dQ� TOTAL FEE $ _ l 42451► Afir; t2-76MK�,0O1os�* ****117_.54 - Cfµ. COSTA MESA BUILDING-SAFETY DEPARTMENT P.O.BOX 1200 COSTA MESA, CALIFORNIA 92626 APPLICATION FOR STRUCTURAL PERMIT For Applicant to Fill in Completely — Use Ink Only BUILDINGADDRESS �O� �c krn v �-- RECE D TE RECEI DATE ISSU D ' I� �^ 2 / A.P.NO.—(r'Z-1S PERMIT NO. OWNER L —� � MAIL _ BUILDING /AIHc' ADDRESS ,rr) hC1 1'— IIIJJJ K/1 f�— ADDRESSTE /I CITY 0.�e54 NOt. j�O /�-rC�e�l!('t TRACT^'V 4i LOT BLOCK CONSTRUCTION NEW ADD ALTER REPAIR LENDER 1 ' BRANCH pp OWNER ADDRESS ) VALUE ARCHITECT TEL.,'C S $ OR ENGINEER I CSL ADDRESS b 1 FIRE ZONE TYPE GROUP I tj APPROVED CONTRACTOR C a 66`) BY DATE ADDRESS 0(.�L� ✓� TEL. ZOPLE I NO. OF USE OF NEW CITY NO.0y'O tfL PLANS BUILDING 1Z, F STATE - CITY YARDS APPROVED YARDS APPROVED LIC. NO. ` LIC. NO. MAIN BUILDING ACCESSORY BUILDING W SIZE NO. OF SLOGS. (FROM C/L STREET) 6. OF LOT NOW ON LOT FRONT FT. 6;;j7--FT. Q USE OF {{�� I j �R, c EXISTING BLDG. V / SIDE FT. h FSeparate permits are required for L. SIDE FT. t FT. electric, plumbing and heating work. / REAR FT. FT. IO (.. USE OF BUILDI N W RKfT12 RF )RIVED DISTANCE BET. BET. MAIN & MAIN SLOGS. ACCESS. BLOCS. VAR.* DATE QC.U.P.# APPROVED ,7 APPROVE a w 0. O 1 hereby acknowledge that I have read this application and state n p�. that the above information is correct and agree to comply with m M. all laws regulating building construction, and I shall not employ i z any person to violation of the workman's compensation laws of the State of California. 3 I hereby certify that I am properly licensed as a contractor under SO. FT. v a THE AMOUNT SHOWN UNDER VALUATION IS FOR the State of California business and Professions Code, Division 3, D Chapter 9, and that such licenses are in full force and effect, or 1 THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the State of California Business v VALUATION PERMIT FEE $ and Professions Code, Ilion 3, Che 9. n t PLAN CHECK $ r 0 o Signature O4KA y [/(�_l goo LL, Permittee '_�I� $ TAX $ • � V U Authorized Agent TOTAL PAID $ •S 1 TESTING [wininq Laboratories,/-Iotlth,EL2 i11t112i=«E, P.O. BOF 42 . 3310 AI.RDOD.T `/.!A'. LONG BEACH, CALIF. 90901. QUI 4201355 . 1213 636-2366 .12141 6266432 BRANCH C«ICES n r. ..�.. .a.... «.N 1191 CdaLBJi IR❑ R]S DEe September 8, 1976 Examination: SC76-3133 COMPRESSION TESTS ON GUNITE CYLINDERS Mr. Errol F. Heesch 12921 Aspenwood Lane Garden Grove, California 92640 yam' PROJECT Pool for R. H. LEGGE ./ 07 ADDRESS 1120 E1 Camino Drive, Costa Mesa SAMPLE FROM ARCHITECT ENGINEER MIX DATE CAST DATE TESTED CYLINDER NO. COMPRESSION TOTAL LOAD, LBS. POUNDS PER SO. IN SIZE. COMPLIANCE CYLINDERS Gunite Swimming Pool 4-1/2 to 1 8-30-76 9-7-76 1 7 -Day 58,000 2,050 611 x 11-3/411 CONTRACTOR Holiday Pools SUBCONTRACTOR Grove Gunite Co. SPECIFIED STRENGTH 2,000 psi CYLINDER SIZE 9-7-76 9-7-76 11 7 -Day 63,000 2,140 6-1/8" x 11-3/41, 7 -day test complies with specifications. MADE BY DISTRIBUTION E. F. Heesch - 2 Grove Gunite Co. Costa Mesa Bldg. Dept. DEtIVERED BY E: Heesch IV "HOLD" 111 V "HOLD" VI "HOLD" 7 -Day 60,000 2,120 61, x 11-3/411 RECEIVED ON 9-1-76 CITE OF COSTA MESA CALIFORNIA 92828-1200 DEVELOPMENT SERVICES DEPARTMENT P.O. BOX 1200 BUILDING DIVISION NOTICE OF PERMIT EXPIRATION DATE: October 15, 1999 TO: Billie F. Su 937 Coronado Dr. Costa Mesa, Ca 92626 PERMIT NUMBER (S) FOR: PROJECT ADDRESS: B98-02215 Re -roof 1120 EL CAMINO DRIVE Our records indicate the above listed permit(s) were obtained for property improvements or alterations at the above address. Per the 1997 Uniform Building Code, Section 106.4.4 Expiration, permits are valid for 180 days from the date of such permit, or the date of your last inspection for the project. According to our records, the permit(s) listed above have not had an inspection for a period exceeding 180 days. If you have a signed inspection card indicating an inspection was conducted within 180 days from the date of this letter, please contact this office so we may correct our records. In some instances an extension may be granted if you intend to commence work and complete the project. If the project is complete and you wish to request an inspection, please call and the staff will be happy to assist you. If you do not contact this office within 10 days, your permits will expire on November 1, 1999. Per Section 106.4.4 of the Uniform Building Code, additional fees may be required to finalize expired permits. If you have any questions, please contact the Building Division at 714-754-4871, between 8:00 a.m. and 4:30 p.m., Monday through Friday. The accuracy of records affecting your property is our goal and we appreciate you working with us to resolve this matter. Sincerely, Karen Collins Office Coordinator 77 FAIR DRIVE Building Division (714) 754-5273 Code Enforcement (714) 754-5623 Planning Division (714) 754.5245 FAX (714) 754-4856 TDD (714) 754-5244 0 O J (714) 754-5273 • Fax (714) 754-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT BUILDING PERMIT Job Address: 1120 EL CAMINO DR Applied: Suite: 937 CORONADO DR 12/11/1998 Vicinity: Calc Valuation: $4,500.00 Phone: Parcel Nunmber: 14161215 Zoning: Applicant: LA RUE,KEN Address: 17662 IRVINE BL $0.00 STE#2 Phone: $0.00 TUSTIN, CA Zip: Owner: SU, BILLIE F Applied: Address 937 CORONADO DR 12/11/1998 Calc Valuation: $4,500.00 Phone: $99.75 COSTA MESA,CA Zip: 92626 Contractor: WEATHERLINE ROOFING Address: 17662 IRVINE BL $0.00 STE#2 Phone: 714-748-9707 $0.00 TUSTIN, CA . Zip: 92780 License: 729560 Arch : Eng: Address: Address: PERMI-- T B98-02215 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 12/11/1998 ,Issued: 12/11/1998 Phone: Phone: Zip: License: License: SCOPE OF PERMIT .REMOVE EXIST. WOOD SHAKE INSTALL 1/2" OSB & INSTALL 25 YEAR COMP. NOTES DATE 1-112-510-6 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 FEE SUMMARY Plan Check: $0.00 Calc Valuation: $4,500.00 Permit: $99.75 — Claim Valuation: $4,500.00 SMTP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $100.25 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left -0=0 Right 0-0 ACCESSORY Front 0-0 Ream 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 , NOTES DATE 1-112-510-6 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 WORKERS' CPMAENSATIOIN DECLARATION: Warmer: under penalty of perjury one of the following declarations: d 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 hich this permit is issued. d 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. rs' compensation Insurance carrier and policy number are: Policy Number: (This section need not be completed if the permit is valued of one hundred dollars ($100) or less.) ❑ in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to became subject to the workers' compensatio Ws o mia, and agree that if I e subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith plicant Signature: WARNING: FAILURE TO SE URE WORKERS' LdAPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN PLOVER O CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($ ,OO L IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN CTIOfN 37 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. CEN ONTRA TORS DECLARATION: I reby affirm that I e licensed under provisions of Chapter 9 (commencing with Section 7000) of Divisi of theQ.sm.�dProfessions Code, antl my license is In full arca and effect. Lic. # U s Contractor's Signature: Date�:n. 11RONSTRUCTION LE DING AGENCY: Erl,it?1eby a that there Is a construction lending agency for the performance of the work for which th is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coos) 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 civ,1 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 contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ 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. (Chep. 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 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 Doee 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). ..........................................................................'u.r'e....................................... t.....'e.p.a..................-..............................................enti........rogr...............utel.......................aterials ? 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 Cade 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 a ennit for such construction or motlification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 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). ................................................................................................................................................................................................................................................................................ 8 Will any pen of the facility 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 required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................... 8 (If yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORV-AT10N 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 Owners) Date And/ uthori d Applicant QQgE6 INSPECTION TYPE gA¢ IDLs CODE 012M INTITIA� 1616 Fixed System Final Fire Prevention - 206 Final Mechani 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Relaining 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"646