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Home My WebLink About920 EVERGREEN PL - Building Permits(714) 754-5273 • Fax (714) 754-4856 • wv+w.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 920 EVERGREEN PL Suite: Viciniry: Parcel Number: 42252105 Applicant: GRAY, WAYNE Address: Owner: RIVERA, EFFIE MAE Address 920 EVERGREEN PL COSTA MESA, CA. Contracror: Q M H S INC Address: 21907 ERIE LN � � LAKE FOREST, CA Zip: 92630 Zoning: Phone: 949 707-5222 Zip: Phone: Zip: 92627-4136 Phone: 949-707-5222 License: 591333 Arch� : Eng: Address: . - -� Address: ISSUED / � , Status: ISSUED Applied: 12/17/2004 Issued: 12/17/2004 � � . Phone: Phone: Zip: License: � � , License: - ` SCOPE OF PERMIT NON-STRUCTURAL "LIKE FOR LIKE" REPLACEMENT OF 10 WINDOWS (APPLICANT-TO COMPLY WITH EGRESS REQUIREMENTS IN � BEDROOMS). . . . - . . , . _ ._ .� . . � . FEE SUMMARY � Plan Check: $0.00 ` Calc Valuation: �. 3a,soo.00 Permit: $11125 - - Claim Valuation: . �a,soo.00 � SMIP Res: $0.50 � ' � � � � % /j. ' �SMIP Com: $0.00 � � � � Other. $0.00 - . '_ , - _ „ � � Inspection: $0.00 , '� . . , '� � � � ��%,' � � t ; � �TotaL• $111:75 � � i� � . � '% � , . . . , . ' . ',� SETBACKS � MAIN STRUCTURE Frant .0-�0 ACCESSORY Front- 0-0 � PARKING Ezistinq:. o • , PLANNING & ZONING �� Rear 0- 0 � Left -0- 0 - Rear 0- 0 Left 0- 0 Requi�ed: - 0 � Proposed: 0 ��Right �0-�0 :" ' `. � Right 0-0 ' - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulalions. (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. INSPEC710NS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all requlred InspecNons and tinal approvel must be obtained. Failure to obtain inspections and final approval will result in the expiration of ihis permit. POR INSPECTIONS CALL: (714) 7545626 >aas�ac �yoo� WORKERS'COMPENSAnON DECLARAnON: � . � , , _ I hereby eRirtn under penalry oi perjury one of the tollowing aeclarations: � � ❑ I heve end will maintain a certilicate ot consent to self-Insure for workers' compensetion, es provided tor by section 3700 ot t�e Labor Code, tor Ihe peAortnence of Ihe work tar which Ihls permit is issuetl. , %�eve and will malntain workers' compensation insurance, as required by section 3700 of the Labor Cotle, for Ihe peAortnance ot ihe work for which Ihls pertnit is issued. M workers' co 5aiion I su-r �ce wrri and li number ere: C /` Cserner:Y� �'�/P �//�� PolicyNumber /7�%OS�'ZI�7 �(This section ne nof 6e com0�efed ll the permit is velued et ane hundred dollars ($100) or /ess.) ❑ I certity iha� in ihe pedormance oi the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workars' compensetion laws ot Celitornie, antl hat if I s�ould become subject to Ihe workers' compensation provislons ol Section 37 0 oi th Labor Code, I s�ell forihwith //cpmply with these provisian // t4opN ac nt Signewre: Dat . �7 / 7� 7 WA{iNINCi: FAILURE TO SECURE WOFKERS' COMPENSAiION ERAGE IS UNLAWFUL AND SHALL SU6IEGT AN EMPLOYER TO CRIMINAL P NALTI AND CNIL FlNES 11P TO ONE HUNDPED TMOUSANDDOLURE(E100,000),INNODITIOfJTOTHECOST COMPENSATION,DAM4GESASPROVIDEDF-0RINSECTION3]OBOFTHELABORCODE,IIJrEPEST,ANDATTORNEY'SFEES. LICENSED CONTRACTORS DECLARATION: � I hereby N rm-Uiat I am licensed under rovisions of Chapter 9(commencing with Section 7000) of Division 3 of ihe force nd effect Lic. N S �� Class / ._ntr§ttofsSlgnaWre: _� s /% � Professions Code, and my license is in full CONSTRUCTION LENDING AGENCY: � ❑ I hereby aHirtn Ihat there is a consWction lentling agency for ihe pedormance of the work for which ihis permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: SlgnaNre: OWNER-BUILDER DECLARATIONS: Date: I hereby eMirm Ihet under penelry ot perjury Ihat I am EXEMPT FROM THE CONTRACTORS LICENSE LAW tor ihe tollowing reason (Sec. 7031.5, Business entl Protessions Cotle: Any dry or counry which requires a pertnit to consiruct, alter, improve, demolish, or repair any structure, pnor to its issuance, also requires the applicant for such pertnit to file a signed statement that he or she is Ilcensetl pursuant to ihe provislons of the Contractore License Law (Chapter 9(commencing wlth Sectlon 7000) oi Division 3 ot ihe Business and Professions Cade) ar that he or she is exempt iheretrom end Ihe basis tor the ellegetl exemption. Any violation ot Section 703L5 by eny applicent for e pertnit subjecls Ihe appllcant to e civil penalty of not more than five hundred dollers ($500).): ❑ I, as owner ot the property, or my employees with wages as their sole compensation, WILL DO THE WORK. and the siructure Is not inientled or offered tor sale (Sec. 7044, Business end Protessions Code: The Contradors License Ww dces not apply to an owner of properry who builds or improves Ihereon, antl who does such work himseN or herself or through his or her own employees, provided that such improvements are not Intendetl or ottered for sale. If, howevar, Ihe building or improvement is sold within one year of comple�ion, Ihe owner-builder will have the burden of proving that he or she did not build or improve for Durpose of sale.). • ❑ I, as owner oi the property. am E%CLUSIVELV CONTRACTNG WITH LICENSED CONTRACTORS to consiruct the project (Sec. 7040, Business entl Professions Cotle: The contracmrs Llcense Lew does no� epply to an owner ol propeny who builtls or Improves thereon, and who comracts for such pmjed with a comractor(s) license pursuant to the Coniractors License Laws.). ❑ I am exemp� under sec. Signawre: Owner ID verified by drivers license. ❑ Ves ❑ No Business antl Professions Coda tor ihis reason: Verilication of Ownership by (type ot tlocument, i.e. - properry tax bill or deed): DIVISION OF INOUSTRIAL SAFETV PERMIT CERTIFICATION: Dnvers License No. Date: Expires: ❑ I hereby certity ihat no excavation five (5) or more feet in Cep�h into which e person is requirad to descend, will be mede in connec�ion with work authonzed by this permit, and that no building simcture, scaMolding, talsework, or demolition or tlismantling ihereof, will be more ihan thirry-six (36) feel high. (Chap. 3.2, Grp 2, Ah 2, Sec. 341, Title 8, Calilomia Administrative Code). ❑ As ownar-builder, I will not employ anyone to do work which would require a permit from the Division of Indusirial Sefary, es notetl above, unless such person �es e permit to tlo such work irom the tlivision. Signawre: Date: �ivision of Indusirial Satery Permit Number. CERTIFlCATE OF COMPLIANCE AND AUTHORVATON OF EMRY: I rsnify under penalry ot perjury ihat I have read this application and state that the infortnation given is correct. I egree to comply with ell state laws end ciry ordinences relating to building constructlon, and euthorize representatives of Ihe City ot Costa Mesa to enter upon Ihe above-descnbed property for inspection purposes. I egree not to occupy or ellow occupancy ot any building authorized by this pertnii un�il fnel inspection. COUE t. INSPECTIONTYPE 1618 Fixed SySlem Final Fire Prevention 1268 200 201 202 203 20a Pool Spa Final Final Pa-Rool Finel BloCk/Retaining Wall Final Faaory Fire Place Final Sign Finel Demolition � COUEt INSPECTIONTYPE 206 Final Mec�anical 208 Final Plumbing 270 Final Electncal 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 FinalBuiltling/Occupancy QAIE U�EL4 Job Address: Suite No Vicinity: Parcel Nunmber: 920 EVERGREEN PL 42252105 Applicant: GRAY, WAYNE Address: Owner: , RIVERA, EFFIE MAE Address 920 EVERGREEN PL COSTA MESA; CA - Contractor: Q M H S INC Address: 21907 ERIE LN LAKE FOREST, CA ELECTRICAL PERMIT Phone: Zip: Phane: Zip: 92627-4136 Phone: 949-707-5222 ' Zip: 92630 License: 591333 Staws: ISSUED Applied: 12/17/2004 Issuetl: 12/17/2004 ISSUED BY „ , • a SCOPE OF PERMIT REF: B04-02128 - NON STRUCTURAL "LIKE FOR LIKE" REPLACEMENT,OF 10 WINDOWS (APPLICANT TO COMPLY WITH EGRESS REQUIREMENTS IN BEDROOMS). - ECECT. PERMIT IS FOR REPAIR OF EXISTING NON-CODE ELECTrIN GARAGE (3 OUTLES & 2 � � SWITCHES). ' ' . � ISSUE FEE Temp service tesl Res.`a/c package_, New Res (1-2 units) New Res{3+units) Pool / Spa � ' Lighting Fixts , Recept Outlets - Switches - � Non Res Appl � , Res Appl � . , Service to 200a . Service to 7000a Service over t000a Motors to 1hp Motors [0 10hp Motors to SOhp Molors to 100hp Motors over 100hp $23.50 $0.00 `, $0.00 $0.00 50.00 $0.00 $0.00 $3.30 $220 $0.00 $0.00 $0.00 50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Quantity FEE SUMMARY , � i - Quaniity., Temp�Dist System / Lighting $0.00 0� Busway/100ft $0.00 %0' , �Standing5ection $0.00 ;r,0� " _ � ' Misc Eledrical Equipment $0.00; �„', 0 _� - Transfortners up to 1 kva/kw $0.00 /- 0 � .....:...........up to t0�kva/kw.;�,i . . $0.00 � 0 . .................up to 50 kva/kvi � . $0.00 _ 0 - � � . ....:.�...........up to 100 kva/kw ,'50.00-' 0 ' � ........�.........over 100 kva/kw' �„ - $0.00 , 0. , � Low Voltage Equipment -- �� 50.00 � -,�-0 , �. Low Volt Wiring System-/ Ckt i 50.00 � 0 - Misc. Canduit � � 50.00 . , 0�� . . Misc. Conductor $0.00 � 0' - Circus-( genbr 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 � NOTICE: The work authorized by this permit shall comply with all applicable handicap access requiremenis 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 requlred inspectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in ihe expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 � 2d48d81N00) WORKERS' COMPENSATION DECLARA710N: � . . � 1 hereby eftirm under penalry ot perjury ona ot �he tollowing declarations: - � � ❑ I heve and will maintain e certificate of wnsent to self-Insure for workers' compensation, es provided for by section 3700 of tha Lebor Cotle, for the peAortnence of Ihe work tor which this permit is issued. ❑ IJiave antl will malniain workero' compenution insurance, as requiretl by section 3700 of the Labor Code, tor the pedortnance of Ihe work for whiCh �his permit Is Issued. AMy workers' compe�n tlon In�su� ce rner end palicy number ere: �—,�/ parner. a/t ////9� �Pol�Number /�� S� Jr� — ZOVT (This section n�be compl ted il fAe permlt is valuetl at one hundred dollars ($700) or less.) � ❑ I cetlify that in Ihe pertormance of the work for which this pertnit is issueq I shall not employ any person in eny manner so as to become subject to the workers' compensation laws oi Calitomia e ree that if I should become subject to the workers' wmpensation provisions ot Section 3700 of It e Labor Cotle, I shell iorthwith corripty with Ihesa pro/vi ' //� A� emSignature: f� ��/ pate: ��-7 �T WAfiNIN6: FAILURE TO SECURE WORKERS' COMPEN ATION COVEPAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FlNES UP TOONE HUNDRED Tl10USAND DOLLARE (5100,000�, IN ADDITION TO THE COST OF COMPENSATIIXJ, DAMNGES AS PROVIOED FOR IN SECTION 3)O60F THE LABOR COOE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aHirm Ihat I am licensetl under ro�s(qnfs of Chapier 9(commencing with Section 7000) ot Division 3 ot Ihe Business,Jar� Professlons Code, and my license is in tull brce enG ettect. Lia M �i ��.7 Class a �J i Contrectors5ignaNre: ,� Data: 3 �� d CONSTRUCTION LENDING AGENCV: . ❑ I hereby aHirtn that there is a construction lending agency for Ihe performance ot ihe work for which this pertnit is issuetl. (Sec. 3097, Civil Cotle). Lenders Name: Signeture: _ OWNER•BUILDER DECLARATIONS: Lenders Address: Date: I hereby aNirtn tha� untler penelry of perlury thet I em EXEMPT FROM THE CONTHAC70RS LICENSE LAW for Ihe following reason (Sec. 7031.5, Business antl Professions Cotle: Any city or counry which requires a permit to construct, alter, impmve, demolish, or repair any strucNre, prior to its issuance, also requires the epplicant for such pertnit to Nle e signetl siatement that he or she is Iicensed pursuant to the provisions oi iha Contractors License Law (ChaD�er 9(commencing with Sectlon 7000) of Dlvislon 3 oi Ihe Business and Protessions Code) or that he or she is ezempt thereirom and ihe basis tor Ihe ellaged exemption. Any violation of Section 7031.5 by any applicant tor e permit sub�ects Ihe applicam to a civil penalry of not more than five hundred dollars (5500).): ❑ I, as owner oi the proDerty, or my employees with wages as their sole compensation, WILL DO 7HE WORK, en0 �he structure is not intentletl or oflered tor sele (Sec. 7044, Business antl Professions Code: The Conlractors License Law dces not apply to an owner of properry who builds or improves thereon, end who does such work himself or herselt or through his or her own employees, providetl that such improvemenis ere not intendad or offered for sale. If, however, the building or Improvement is sold within ona year ot comDletion, ihe ownar-builder will have �he burtlen of pmving ihat he or she did not build or improve for purpose of sale.). � ❑ I, es owner of the propeny, am EXCLUSIVELY CONTRACTING WITH UCENSED CONTRACTORS m construct the project (SecJ044, Business and Professions Code: The comractors License Law tloes not epply to an owner of propehy who builds or Improves ihareon, antl who contracts tor such project with e contrector(s) license pursuam b the Contractors License Laws.). ❑ I am e:empt untler sec. SignOiura: Owner ID varifietl �y Crivefs license. ❑ Ves ❑ No Business and Professions Code for this reason: Vedllcetion of Ownership by (rype ol document, i.e. - property ta+c bill or tleed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: Dnvefs License No. Date: Eapires: ❑ I �ereby certify �hat no excavation five (5) or more feet in dep[h into which e person is requiretl to tlescend, will be made in conneciion with work euthorized by this pertnit, and thai no building sWcture, scaftoltling, falsework, or demolition or dismaniiing Ihereoi, will be more Ihen thirty-six (36) teet high. (Chap. 32, Grp 2, Art 2, Sec. 341, Tula e, Califomia Atlministrative Cotle). ❑ As ownerbuilder, I will not employ enyone to do work which would require a permit from the Oivision of Indusinal Safety, as notetl a6ove, unless such person has e permi� �o do such work trom �he division. Signature: Date: Division oi Industrial Safery Permit Number. CERTIFlCATE OF COMPLIANCE AND AUiHORVJITON OF EMAY: I certity under penalty of perlury that I have read ihis application and stete that the intortnation given is correct. I egree to comply with all state laws and ciry ordinances relating to Duiltling construction, and authonze representatives of the Ciry ot Costa Mesa to enter upon the ebove-descnbed property for inspection purposes. I egree not to occupy or allow occupancy of any building authorized by t�is pertnit until final inspection. COOE �. INSPECTIONTYPE 1618 Fixetl Sysiem Final Fire Preveniian 12fi6 200 201 202 203 204 Pool Spa Final Final Re-Roof Final BIocWRetaining Well Finel Factory Fire Place Finel Sign Final Demolition PdIE 1[�leLi P1 CQOE 1 INSYECTION TYPE 206 Final Mechanical 20B Final Plumbing 210 Final Elecirical 212 Final Fire Preventlon 220 Final Planning Approval 222 FinalSite 250 Final Builtling/Occupancy PAIF. II�Lfl • ��E♦ (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.c��MBING PERMIT P FAIfi DRIVE, COSTA MESA, CA 92626 JobAddress: 920 EVERGREEN PL Suite No Viciniry: Parcel Nunmber: 42252105 App�icant: RIVERA,EFFIEMAE ISSUEDBY: Address: 920 EVERGREEN PL . _- - ---- -_, � r ��.i�Phonei ." 949-548_6391 ,. - --., COSTA MESA, CA-� � !"'�-� " �-- i"2ipT, 92827-4136� - � -' � ' �%�r,f%�% r' �� ' i i i= �-'� � r, ri' " � 7 � A Slatus: ISSUED Applied: 07/26/2006 Issued: 07/26/2006 ��Il!� ( "'' +, ' � ., � /� . I / A''.'"'``.-� i Owner: RIVERA;EFFIE MAE� � � . � i ` /` � � %�''J \�� , ,,,, , , . � � � , _ _ _ � , I , �.� r�,;� Address 920�EVERGREEN PC � � � \ �� v , � Phone -949=548-6391 � � �\ � \, \} �\ > `� COSTA MESAi CA�/ ��'i-' � Zip: 92627-0138` ' �0��\ ��/� \ rJ � \ // �% / -\ 1 \ \ %� /1�, � �� /�i �� `\, \� �� /,/ii '��,i� % mtractor: OWNER=BUI�DER / 1,',_'1 '%i' Ll�.��/ / U,� � � • '� �-� r „ -� � '� ,` � �� /,', ��r �� +�i il � �- / -' � �� ISSUE,FEE Backflow irrigation�� Backflow Preventer� BathWp� —�� _.. ..:, o.._....:. � Expansion Tank" Gas Earthquake Gas (1-4,outlels) Gas (Over 4�outl� Gas Repipe; c�� Gas Service� � Interceptors (Gre Interceptors (San i 1%if� '�� ``� �� i%��/ Phone: �.' �� l �� .!� ///.;,� . - -- � : . • � \t�� \ � � ` I/ Zip .. ..A A \�: � v . � 7 � , License � 000000 '� _ �.� �, � � l� /i . 'n .` � . . . . \ `i_ � ��. , � . _ ,. � �—' ,�� ' . . � ., � � ; ` ', 1� � � J AMT -` $23.50 �I$D.00 $o.00 i $0.00 ; so.00 $D.00 50.00 ' $D.00 '� $0.00 \� � $D.00 �` $0.00 � �, �� $0.00 � l =- ��' _ - - SCOPE OF PERMIT - ` � � � ` _ , � _ ,;�, -, � �� , ., , ., - 2EPIPE FOR ENTIER SFD. � �'� ��,�1 � , ',� '�' '�_ __-� V" � 1 �v'Ii1Vt %—^ �-'' � � FEE SUMMARY � A1 1�,(JP I �` �j 1 � - - �— - . ' - - - — AMT QTY- _ - i t J �� " AN % � � �� Laundry�Tub�/ Washe� � 7?�$0 00` ; rt0� �� A ��V�Sump Pump r �� ; i � $0.1 � $0.00-. �, $0.00�. � ✓ �C 0 �...:. �= Landscape Irriga6on ��. l. 1_$0 00. � 0 � �Swimming Pool � / � 0'== -_- �- `P-T�ap` :--�- --_- � --�=-�$0.00 --p---- --;'Tra Primer � I P �r I r 0�� PressureRegulator $0.00 �0� / Urinal � �;�d! �, 0� P��ocess,Piping (per 10 ft) $0.00 ;Or, � Vacuum Brkr BkOow(14) ;' 0'�r= � v Receplors � �� j��$0.00� �, 0 �� - �; � Vacuum Brkr Bkflow(5+) ;; 0� C—'Sepfic Tank -'� ' ,"$0.00� ; 0"�"'-" -" Wash Basin % i%� �_ 0 ! """ SewerCap'forDemo`= --`$0.00 '� 0 - -""" �- WashBasinSet��; � 0' SewerConnect $0.00�1 0 �: Waste and VeM�System_ ,; OJ Sewer Private Line - 'S-$0.00'_ 0 '^ Water Closet (Toilet) 0 Shower i:$000? r�0 WalerHeatec/vent �� 0� Sink, bar $0.00 0 Water Piping (Inst or,Rep.)� �` "�� $0.00 0 WaterRe,pipe� (, �'�5� 01 Sink, commercial '•�^��- 0� Sink, Flooi,��"�; -' �.,�'-A,$0.00 0 N/aterSeivice `��/ 0 Smk kitchen -, �$000 ' 0 Water-Sokener �, 0 �.Smk 50ivice/mOp� � �� _ $000 j+'?Oi�_ -� �-.,_OTHER%` � � � 0 'ti , Spa-(private)" � ' $0 00 �' 0 � - �- �%� VIOLATION � �J �U �0 � '�, Spa (publlc),� ,>� �' $0.00 , 0 �BL'AN CHECK �U� �0�� _ � � �- _ : ,� �.REWSPECTION /� � i _ �V� �� ., '`' -_.� ;- TOTAL�CALCUL4TED��S: ��` r.. �� "'�-- � � � `�_`�'=_ - =' � i A� � �� /�1�� ._.J ; ,.....�.� .��.... �...-.� .. �.. ... `�... .� r. �t - ... V ' i , `.' 2 �y,1.� ��!"�I _�,f�� ` 1;� ii�i t 1 l� _'j � �.: _ " r� �� "`- � �_- ,". �.: ,. �:�,,�, 0 0 0 0 1 0 0 $0.00 $0.00 $0.00 0 E33.30 NOTICE: The work aulhorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related 'regulations. (Ord. No. 92-28, § 7, 12-21-92) E%PIRATION: This permit shall automaticylly 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 requlred Inapectlo�a end flnel approval must be obtained. Failure to obtain inspections and final approval will result in ihe expiratlon of lhis pertnit. FOR INSPECTIONS CALL: (714) 7545826 2408d8 (fl�00) WORKERS'COMPENSATION DECLAFiATON: . � � I hereby eflirtn under penalry oi perJury one ot the following tleclarations:' � � �` � ❑ I have entl will meintein e cenificate of consent to selt-Insure tor workers' wmpensation, es provided tor by section 3700 of ihe Lebor Coae, for the pertortnance of t�e work for whiCh this permi� I9 I55ued. . ❑ I have antl will meintain vrorkers' compensation insurance. es required by section 3700 of Ne Labor Code. kr the peAortnance of Me xrork br wh�h ihis pertnit is iswetl. My workers' compensallon �nsurance cerrier antl policy numDer ara: Certier. PWicy Number. (Th/s secfion neetl irot be completed!! fhe permit is veWed et one hundred dWlars ($100) or less.) � 'cel Nfy Iha� in Ne pertortnance of the work for which this pertnit is Iuue4 I shall not employ eny person in eny manner so es lo become subjecl to the workers' compensetlon lews o1 Celtlomle, enA egrea t�at If I shoulC become sub�ect to ihe workers' compensatlon provisions of Sectlon 3700 of ihe Lebor Cotle, I shell torthwlih compty_with tt�ese provisions. - / ApPlicantSipneWre:J �%�-�4 iiio//o/ Date: �l—� �ii "�L� � � � WARNINO: fAILURE TO SECURE WO (ERS' COMPENSATIIXJ COVERAOE IS UNLAWFUL M!D SHALL SUBIEGT AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL FlNES UP TOONE MUNDRED TIqUSAND DOI.LARE (5100,000), IN ADDfTION TO THE COST OF CqAPENSATIIXJ, DAMAGES AS PflOVIDED FOR IN SECiION 3]W OF THE UBOR CO�E, IMEREST, AND ATTORNEV'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby attirtn that I em Ilcensetl untler provisions oi C�apter 9(commencing with Section 7000) oi Division 3 of the Business end Professions Coda, antl my license Is In tull force and ettec�. Lic. M Class p Contractofs Signature: Date: CONSTRUCTION LENDING AGENCY:� ❑ I hereby eHirtn Ihat there is a construction lending agency for the peAartnance ot the work for which this pertnit is issued. (Sec. 3097, Civil Cade). Lendels Nama: Lendefs Address: Sipneture: Date: OWNER-BUILDER DECLARATIONS: I hereby eHirtn that under penalry of per�ury thet I em EXEMPT FROM THE CONTRACTORS LICENSE LAW For the following reason (Sec. 7031.5, Business end Protesslons Cotle: My ciry or counry which requires e pertnit to construct, elter, improve, demolish, or repair any structure, prior to its issuence, also requires the applicent for such permit to Ola e signed stetement Ihet he or ahe Is Ilcensed pursuant to Ne proNsions of ihe Contrectors License Lew (Chapter 9(commencing wlih Sectlon 7000) of DlWsion 3 of t�e Business end Professlons CoOe) or Iha� he or she is exempt therefrom and Ue basis for the elleged eaemption. Any Nolation of Sectlon 7031.5 by any epplicent for e pertnit sub�ecis�he epplicflnt to e civll penalry o1 not mara than five hundretl tlollers ($500).): ,�,.-I,-es owner o1 the pmperry, or my employees with wages es thelr sole compensatlon, WILL DO THE WORK, entl ihe structure Is not Intentletl or offered lor sele (Sec, 7044, Business end Professions Catle: The Coniractors License Lew tloes not apON �o an owner of property who builds or impraves Ihereon, end who does such work himself or herselt or �hrough his or lier own employees, provitletl that such Improvements are not intendetl or oNeretl for sale. If, however, Ihe building or improvement Is sold within one year o1 completion, Ihe owner-DuilAer will have �he Durtlen of proving ihet he or she did not builtl or Improve lor purpose of sale.). • ��, as owner of the property, em E%CLUSIVELY CON7BACTING WRH LICENSED CONTRACTOPS to wnsiruct Ihe prqact (Sec. 7044, eusiness and Professians Code: 7he contrectore Llcense Law tl s not appty ta en owner ai property who Dullds or Improves therean, antl who contracts tor such pmject with e contrector(s) Iicense pursuam to the Comrectors Li nse Laws.). ❑ I em exempt unCer sec. Business entl Profeuions Code for this reason: signewre: �s�,��u . �!� -�s c E �� -'� —"��--��- Explres:-� /�/�� Vedflcatlon of Ownership by (type of document, I.e. - property tax bill or deed): t'-�._ . DIVISION OF INDUSTRIAL SAFETV PERMR CERTIFICATION: ❑ I hereby certify �hat no excevetlon five (5) or more teet in depth into which a person is required to tlescend, will be mede in connectlon with work euthorizetl by ihis pertnit, and lhat no bullding siructure, swXoltling, talsework, or demolition or dismentling thereot, will be more ihen thirty-six (36) feet high. (Chap. 32, Gry 2, Ar12, Sec. 341, Title 8, Califamia AdminLstretive CoOe). ❑ As owner-Duiltler, I will not employ enyane to do work which would require e parmit irom the Division ot Indusirial Satery, es notetl eDove, unless such person hes e pertnit to do such work irom the tlivision. SipneWre: Date: Dlvision of Indusirial Sefery Pertnit Number: CERTIFlCATE Of COMPLIANCE AND AURiOR¢ATON OF EHfAY: I certify under penalry ot perjury that I have read this application and state that the informalion given Is wrtect. 1 egree to comply with all stete laws and ciry ordinances relating to building construction, and auNorize representetives of the Ciry of Casta Mesa to enter upon the ebove-�de�sjcn"bed' proy"er�ry tor inspecUon purpyegs. I agree not to occupy or ellow occupancy ot eny building authorizetl by f�Is permit until Mel inspeclion. �� /I,/ C � � � O�, — —O 6 _ �� a r--fiigneNre Of Legal,Owne�(sJ , ,�y :��,;; Date-1 _�....- � _ , iJ COOE1, INSVECTIONT'PE pAIE 1618 Fixed System Final Fire Praventlon � 1288 Pool Spa Final 200 Final Re-Raof 201 Final BIacWRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition COUEt- INSPECTONTYPE 206 Final Mec�aniCal 20B Final Plumbing 210 Final Eledrical 212 Flnfll Fire Prevention 220 Final Plenninq Approval 222 Final Site 250 Final BuildinWOccupern (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 lob Address: 920 EVERGREEN PL Suite No Vicinity: Parcel Nunmber: 42252105 Applicanc HOPPER,THOMAS Address: 915 LAKE ST � ��,- . HUNTINGTON BEACH, CA '.' Owner. RIVERA; EFFIE MAE Address 920 EVERGFtEE1V PL COSTA MESA, CA Contractor: JK CONSTRUCTION Address: � 915 LAKE ST PLUMBING PERMIT Phone: (714)404-9846 T- Zip: 92648 Phone: Zip: 92627-4136 Status: ISSUED Applied: 07/12/2004 Issued: 01/12/2004 ISSUED BY: i _ � � _ �'. . . . � � . Phone: (714)404-9846 HUNTINGTON BEACH, CA Zip: 92648 � � License: 450297 Arch / Eng : �- ± - - . � � - . . Address: . Phone: . � - � , . - _-- . - . -_�Zip: ' � _ . ,- ' License: -.. - - -- �_� " .�_ ' , ' SCOPE OF PERMIT � � �� REMOVE AND REPLACE WATER HEATER. , � ' . �� . i, _, . � � � �r�-FEE�SUMMARY �� . � % AMT QTY- . _ AMT QTY - '- , _ - ; � - � AMT ISSUE FEE . . $23.50 ' � � � "Laundry Tub / Washer $0.00 0 Sump Pump $0.00 BackFlow irrigation � $0.00 0�� Landscape IrrigaUon $0.00 0 Swimming Pool - "�$0.00 8ackflow Preventer $0:00 0 P-Trap $0.00 0 Trap Pnmer � $0.00 Bathtub $0.00 0 Pressure Regulator $0.00 0 Udnaf � � , $0.00 Clarif er System ' $0.00 0 Process Piping (per 10 ft) $0.00 0 - Vacuum Brkr Bkflow(1-4) $0.00 Connect (Ice,Soda,etc) � $0.00 0 , Receptors �$0.00 0 Vacuum Brkr Bkflow(5+) $0.00 Dental Units .$0.00 0 Septic Tank $0.00 0 � Wash Basin , $0.00 Dishwasher $0.00 � 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) i0.00 Drain, Roof $0.00 0 Shower ' $0.00 0 , Water Heater / vent $12.30 Drinking Fountain $0.00 0 Sink; bar $0.00 �- 0 " Water Piping (Inst or Rep.) $0.00 Expansion Tank $0.00 0 Sink, commercial - $0.00 0 Water Re-pipe $0.00 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 QTY 0 0 0 0 0 0 0 0 0 0 1 0 0 0 NOTICE: The work authorized by ihis permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) IEXPIRATION: This permit shall automatically expire and become void if work is not commenced within 1 BO 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 requlred inspeetlons and (inal approval must be obtained. Failure to obtain inspections and final approval will result in Ihe expiration of this permit. FOR INSPECTIONS CALL: (714) 75M5626 zaaaae (�oo� WOHKERS' COMPENSATION DECLARA710N: — I hereby affirm under penalry ot perjury one of ihe following declarations: ❑ ave end will maintain a centliwte of consem to seN-Insure for workers' compensation, es pmvided Por by sealon 3700 of the Lebor Code, far the pertartnence of ihe work tor which this pertnit �5 issued. �� 1 hav nd will maintain wo�ers' oompensation insurance, as required by sectlon 3700 ot ihe Lebor Code, foi Iha pe�rtortnerke of.Ne work for w�ich ihis pertnit Is issued. __ ' cyp,pe�setloq Insurence�grrier epd policy number are: — _ PolicyNumber: ��/�s"� one hundretl do/lars (8100) or less.) ❑ I certity that in the Dertormence of the work tor which this permit is issued, I shall not employ any person in any manner so as to become subject to ihe workers' compensation lews ot Celi�omie, ya tl�9ree that it I should become suDjact to the workers' compensatlon provisions oi Section 3700 oi the Labor Cotle, I shall forthwith �PIy_w� :p�w�sio^y i/ Applicant'SigneWra: /I �4 �—oace� ! )=Z� n y WARNING: FAILURE TO SE WORKERS' COYJeNSATION C1�VERAGE IS UNLAW FUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND GNL FlNES UP TO ONE HUNDRED T}IWS4ND DOLLARE (5100,000�, IN �OITION TO THE COST OF COMPENSATION, DAAWGES AS PRWIDED FOR IN SECiION 3]Ofi OF THE L4BOR CODE, IMEFEST, AND ATTOqNEV'S FEES. LICENSED CONTRACTORS DECLARA710N: I hereby ettirtn Ihat I am licens 0 untler mvisions of Chapter 9(commencing with Section 7000) of Division 3 of ihe B_� ss�yid C fe�5ipps Code, and my license is in full rorce.arH:e e�LTN� O �—Class D 5� 1 Contrectaf� �' neture: 6 Dete:� � — i/" � / � ' T CONSTRUCTION LENDING AGENCY: �� ❑ I hereby aXirm that Ihere is e consiruction lentling agency for the pedormance of the work for which this permit is issued. (Sec. 3097, Civil Cotle). Lendafs Neme: Lenders Address: SigneWre: OWNER•BUILDER DECLARAT70NS: Date: I hereby eHirtn thet untler penelry oi Derjury Ihat I am EXEMPT FROM 7HE CONTRACTORS LICENSE LAW for the following reeson (Sec. 7031.5, Business entl Proteulons Code: Any ciry or counry which requires e permit to consWct, alter, improve, demolish, or repair eny structure, prior to its issuance, also requires the applicant for sUch pertnit to file a signed stetement Ihet ha or she is Iicensed pursuant to the pravisions of the Conirectors License Lew (Chapter 9(cammencing with Section 7000) of Division 3 af the Business and Protessians Code) or that he or she is exempt tharefrom and the basis tor the alleged ezempiion. Any vi0�ation of Sectlon 7031.5 by any applicant tor a pertnit subjects the epplicam to a civil penelry of not more than five huntlred dollers ($500).): ❑ I, as owner ot Ihe property, o� my employees with wages as their sole compensation, WILL DO THE WORK, antl ihe structure is not iniended or otteretl tor sale (Sec. 7044, Business end Prolessions Coae: The Coniractors License Law dces not apply to an owner of property who builtls or improves thareon, and who does such work himself or hersell or through his ar her own employees, provided ihat such improvements are not Intended or oHeretl for sale. H, however, Ihe building or impro�ement is sold within one year of completion, the owner-builder will have the burden of pmving that he or she did not build or improve for purpose of sale.). ' ❑ 1, as owner ot the propeM• am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business antl Professions Cotle: The contrectore LIcB�se Lew tloes not apply to an owner oi properry who �uilds or Improves thereon, end who coniracts for such project with a contrector(s) license pursuent lo Ihe Con«actors License Laws.). ❑ I am eaempt untler sec. Business antl Professions Code tor this reeson: Signature: Date: Owner ID verified by dnver's license. ❑ Ves ❑ No Dnvers License No. Venficetion of Ownership by (type ot document, i.e. - property tav bill or deetl): Expires: DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATON: ❑ I hereby certity ihat no axcevetian tive (5) or more teet in depih into which e person is required to descend, will be made in connectian with work autharizetl by Ihls permit, and ihat no builtling strucNre, scaffolding, falsework, or demoli�ion or tlismantling thereof, will be more than thirry-six (36) feet high. (Chap. 32, Grp 2, Art 2, Sec. 341, Tltle B, Celltornla Atlm�Nstrative Cotle). ❑ As ownervbullder, I will not employ anyone to do work which would require a permit from �he Division ol Industrial Setety, as noted abave, unless such person has e permit Io do such work irom ihe division. Signature: Date: Division of Industnal Satery Permil Number. CEHTIFlCATE OF COMPLIANCff AND AUfliORVATION OF EMAV: I cenify under penalry of perjury that I have read Ihis epplication and state [hat lhe infarmation given is correct. I egree to comply wlth 911 state lews end city ordinances relating to building consiruction, end euthodze representatives ot ihe City of Costa Mesa to enler upon the ebove-described property for inspeclion purposes. f agrae not to occupy or sllow occupancy oi any builtling euthorized by this permit uMiV final inspection. CppE �. IXSPECTIONTYPE Qdg, � 1818 Fixed System Final Fire Prevention 1268 200 201 202 203 204 Pool Spe Final Final Re-Roof Final Black/Retaining Well Final Factory Fire Place Ftnel Slgn Final Demolition GOOE I INSVECTION TYPE 20fi Finel Mechanical 208 Final PlumDing 210 Finel Elednwl 212 Finel Fire Preventian 220 Finel Planninq Approval 222 Final Site 250 Finel Building/Occupancy Q� �� •_ • � ► 1635 WESi G4YLORD iT. P.O. BO% 9065 �ONu BEACH 10, CA4FORNIA MEn�oc�c 5-9a93 NEv�Os 6-5176 T�nr�n3n EsaminaHon Nu. Vroject Sample from Architect Contractor �fic \Vuter, gal./sk, cemunt �FiaxecpL S i ze Date cast Date tested j- :. _ . t � �t� _:�t � _ . Calinder No. CO\�IPRI;SSIOV� 'I'EST I'otul luad to d�sUuction, Ibs Poiwds per squarc inc1� Cvlindor made bp C�dinder delivered hv Cylindcr rece,ived rw cc= Corson Pools�2 Costa Mesa Bldg. Dept. SA �ab BRYNCN OFFICE: 39815 N. 61n SL EP.ST � P.O. BO% 9"1B � PA�MO/+�E, C/LIGpRNIA WINo50F i-5911 cSouE�iEzn �a�lFo¢nla October 15, �9r79 GUNITE HGP()HT OF�Q4�XX1'EST CYL;INDER c59-465i . SW[M POOL - R. E. 0'Neil - 920 Evergreen, Costa Mesa, Calif. For - Corson Pools ' East Wall - Swim Pool Permit #10296 Corson Pools Sub-Contractor: Commercial Gunite Co N. Hollywood I :1�2 Victor, Smith-Emery Test, 151 sks. used 6.25 x 12 g_I%-59 (2:30 pm) Fullerton � 9-�-59 I o-15-59 , d. NE1L j2" Cube*t 2?�' M 7 days 52,000 4,�,5�''� George H��Pa. Van Arnam � 9-2i-59 28 days 50�000 �,770 . * ylinder No, when stripped, shmwed rebound laminations. A 32" Cube was cut from the sound portion and tested giving results noted. � No e'�Low break on CylTnder 2 dae to rebound laminations. T\1'I\ING L:1I30RATORIP:S OF SOU'CHER`; CAL[FORNIA ��..-� ��...� ;i •LL 11POI�T� .�R< �u��ITT[D �� TN[ CON�IDWTI.�L �IM��RTY 01 CLI WT�. LVTXOIIISAT�pN �OI� IRI�4C/�TIOM O� W I� I�tIOI�T�. CONCLUt10JLL. OR R- TI�ACT� IROM OI� Rf9�l1o1X0 TM[Y I� I�[��M10 �dGIMG WI� W111TTtN.V�1�OYAL M1� 1 uVryK'Ipt[f�T10N i0 <LI[MI�. TX[ �Y�LIC N10 WI�l4V0. � . OWNER ROBERT O�NEIL ' DATE 9/2/59 JOB ADDRESS 970 Fbaro,-ppn Pla�e BUILDING PERMIT NO. �n�q(� GENERAL CONTRACTOR QD�nn 4urim�ppjg VALUE $ 2�(�s(1 �0 _ AP. No. j_15-38Z-3Iy LOT 1 TRACT FIRE ZONE DESCffiPTION OF WORK PVt. SWllft p00 I' `ECTIONYn(in.�_ Q GL�.�� DATE I GRf1iTP .T TYPF. TTT 7,ONF, Rl SU6CONTRACTOR 10296 b ap fy� �r ., � ti � 1V�� .� { ,�`� ��.C�I�L� _ COSTA MESA BUILbING-SAFETY DEPARTMENT � 2�� P.O. BOX 31] COSTA MESA. GALIFORNIA � FINANCE DEP(. , fOR APPC/CANT TO F/LL /N COMPLFTELy APPLICATIOfVEFORT�PERMIT TYPE OR PRINT BUILDING BUILDING G7� �1 � �C`/ERC'� RC �N � ADDRE55 � �� D r r COSTA MESA, CALIFORNIA FOn OFFICG USG ONLY OWNER PD �R� V l/' L I� I REGEIPT NO. I PERMIT NO. MAIL REGEI DATE FECEIVEOp /�D E 5 E ADDRESS O �� I � 7 ��/ / %� QTY �v/�N TNO. ADD E'SS V �-�Y nRrwi7eci N - � �ia � COSTA MESA, CAUFORNIA O� ,INEER C NO. AD�rtE55S>, A G� f) ZpNE TYPE GROUP ..v STATE (7<< S qppqOVED CONTRACTOR OOFLIC. NO. SC S3 BY OATE r ADDRE55 3 ^2K �rf {%CL� %OiU �G��{� �/W+� ZONING IEGAL I LOT � L-^J I I /%� a �QHE / I NO. OF I USE OF NEW OESCFIPTION NO. J J BLOCK TRACT P�ANS 7/ BIIILDING A.P.NO. � �� APPROVED - BY DATE �+ SIZE 7J' X� O S / I Now orv LOTS I REQUIRED ALLOWED OF LOT USE OF p w � ICENTER LINE ST.) ) EXISTING BLDG ��5. b' `G�%' Cl R-'C FRONT S T FT. IN. o � SET9ACK LINE FROM � c[view OF STREET /a� f' REAR YARD R. SIDE � FT� IN. � / SIDE YARO LEFT � IRIGHT �� L.SI�E � FT. IN. DESCRIPTION OF WORK REAR "—B" Fr. iN. NF I^ II ALTERATION I II A�DITION I REPAIR I II MOVING I II DEMOLISH I � 5 Z,EDING // � �S/ ROOMS STORIES b EXTERIOR WALL IROOF COVERING COVERING 1 HEREBY ACKNOWLEOGE YHAT 1 HAVE FEAO THIS APPLICATION ANO STATE THAT THE ABqyE IS CORRECT AND AGREE TO COM- 7HE AMOUNT SHOWN UNOER VALUATION IS FOR THE PLY WITH ALL GITY OROINqNCES AND STATE LAWS REGULATING P�RPOSE OF ESTABLISHING A PERMIT FFE ONLY. eui�oinc corvsirsuciiorv. //n VALUATION / SIGNATURE OF � MA.�.. �� q�-� � PERMIT FEE $ / D/ PERM177EE 'titi�C//'/ // � - l -/ '� a ,/ //'�' q /J � � il PLAN CHECK S S� AUTHORIZED AGENT . (�/�VN�-� lX $ ( � TOTAL FEE $ �� OWNER ��n.� j$2�, $c MI'S. Robert E. . DATE � 10-�1-5� ]OB'ADDRESS gQ0 Everereen Place � BUILDING PERMIT NO. 5875 G��IE$AI��ONTRACTOR' OWriQT-BU1�.dQT VAL[IE $ 520:�0� - � ' 171Z FIRE ZONE - DESCRIPTION OF WORR E f—"`UP J TYPE V ZONE RZ ECTIONS � DATE I SUBCONTRACTOR I DATE PERMITSNUM6EF coat Test � � � � � S90$ �OSTA ME°iA BUILDING DEPARTMENT ' ' P. O. 80% 31� - � COSTA MESA. CALIFORNIA FOR APPLICAI�(7' TO FILL IN BUILDING ^ 9 ADDRE55 �(�vgJ.G'_�� /LF COSTA MESA. CALIFORNIA I OWNER ER CONTRACTOR ADDRE55 LEGhL LO{ � OESCRIPTION NO. A.P. NO. � � S FEE, R�f CEIVED C� t � � y s�7-�� FINANCE DEPT. CITY OF COSTA MESA APPLICATION FOR PERMIT BUILDING FOR OFFICE USE ONLY RECEIPT NO. �PF�RMIT N� L � .'CJ- /V��'1 � No L� �-L39/ ADDRE'S5 �j z_ v C-�t-zg� tP... P/ LIC. � .No. . COSTA MESA. CALIFORNIA CITV LIC. �orvE NO. TEL APPF NO. BY K ' TRACT //� �� C� v � O.�OF BLOGS. � OW ON LOT I USE OF �2J . ' , � E%ISTING BLDG. ��/��pKrp SETBACK LINE fROM /J ^/ . CENTER OF STPEET �/�C�� I � SIDE VPRD RIGHT e � DESCRIPTION OF NEV ALTEFATION `� REPA�.. MOVING S ZIE DING / D ��/ ROONS �P EXTERIOR , ROOF COVEqING COVERI� USE OF NEW BUILDING NI s. i� h ADOITION DEMOLISH STORIES PLANS / � �//1>.r4, . DATE �� Y•�.� I CORRECTIONS CITY OP A�R SUBJECT TO DEPT. REG. STATE TMAT iHE ABOVE IS CORRECT ANO RGREE TO COMPLY WITX ALL CITY ORDINANCES TN� STnTE UWS FEGUTATING BUILDING CONSTRUC- norv. � � � VAWATION �� PERMiT FEE $ SIGNATURE OF � � PERMITTEE ' .�,� $ , ( � v � PLAN CHECK $ '� V / AUTHORIZED AGENT ' TOTAL FEE S �\ :�: ORAMGE COUNTY BUILDING DEPARTMENT . APPLICATION FOR PERMIT � ' • 636 North Broadway . � ' � � � p � � � SANTA ANA. CALIFORNIA • � �l �� t� r = w J Z J a • a ' O a a a : . .� ' . ; _ . V .. ��: ' �' ,. . . _. , . '� • i•. , / _ :�'. �`.: � . ',. \,.�\ _ . . . . ;\ .,-` ' STREET PLOT PLAN Show- location and distances from property line and between buildings. � - :.� . , - - ..:�, . ; � - �- � - ��-- j ._ .. ., . . . �. � - � --� ---- i'_---"-- -..._ _ . • F' � .