HomeMy WebLinkAbout2468 FAIRWAY DR - Building Permits�
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CITY OF COSTA MESA �
OTpMFq BUILDING DIVISION
it�� 77 FAIR DRIVE, COSTA MESA. CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • �wiw.ci.costa-mesa.ca.us
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" FOR INSPECTIONS CALL: (714) 754-5626
�'""'°�°� PERMIT NUMBER: 609-00143
PERMIT TYPE B_ROOF2
APN: 11910301
JOB ADDRESS: 2468 FAIRWAY DR CM
Vicinity: RESIDENCE AND ATTACHED BREEZEWAY
Squares: 3000
STATUS:
DATE ISSUED:
ISSUED BY:
Suite/Unit:
Valuation:
ISSUED
0810312009
BJK
$8,000.00
SCOPE OF WORK: REROOF RESIDENCE AND ATTACHED GARAGE W/BREEZEWAY: T/O EXISTING WOOD SHAKE, 1/2" OR 7/16" CDX
SHTG, FELT PER MFGR'S SPECS, APPLY "30-YEAR COMP SINGLES." 30 DEGREE PITCH (ADVISED APPI
INSPECTOR WILL ADVISE OF PITCH WHEN INSPECTION IS MADE). 30 SQUARES
OWNER: WOLLERMAN, HERB�RT
PHONE:
APPLICANT: WOLLERMAN, CARMEN
PHONE: 949-241 •7992
CONTRAC70R: O W NER-BUILDER
Address: Unit:
City/State/Zip:
ARCHITECT:
ENGINEER:
FEE SUMMARY
Reroof Plan Check:
Reroof Permit Fee:
Reinspection Fee:
Bldg Std Admin Fund
TOTALFEES
$0.00
$153.25
$0.00
$1.00
$154.25
Address: 2468 FAIRWAY DR
City/State/Zip: COSTA MESA, CA
Address: 2468 FAIRWAY DR
City/State/Zip: COSTA MESA, CA
License No.
License No.
I.9:P721�1
License No. 000000
CELL:
PHONE:
PHONE:
Unit:
Unit: :
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 pertnit.
CODE/. INSPEC110NTYPE �Alf IN1111AL5 COOEt INSPEGTIONME OATE IN7ITAL5
1676 Fixed System Final Fire Prevention 206 Final Mechanicel
12fifi P001 SDa Final �G� 208 Final Plumbing
200 Final Re-Roof PJ 210 Final Electriwl
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Faclory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final BuildinglOccupancy
WORKERS' COMPENSATION DECLAR.4TION:
I hereby aKrm under penalty o( perjury one of the following tleclarations:
❑ I have and will maintain a certifcate of consenl lo sel(-Insure (or workers'
compensation, as provided (or by section 3700 of Ihe Labor Code, for the
peAormance of �he work for which Ihis permit is issued.
� I have an0 will maintain v.orkers' compensation insurance, as required by
section 3700 of the Labor Code, for the pertormance of Ihe work for which this
pertnit is issued. My workers' compensation Insurance carrier and policy
number are:
Carrier:
(ih�s semm �eed iroi be mmp�ereenme ce��+s �alued at one hundred dd�ars (Stoo) o� iessJ
Policy Number:
❑ I certify that in the peAormance of [he 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
6ecome subjec[ to lhe workers' compensation provisions of Sec[ion 3700 of
the Lahor Code, I shall (orthwi[h comply wilh ihese pmvisions.
APO�����'S Signature
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
(5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATI�ORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrm ihat I am licensed under provisions of Chapter 9(commencing
with Section 7000) o( Division 3 of the Business and Professions Code, and
my license is in full force and eRect.
Lic. # Class #
Conlractor'S SgnaWre
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby aKrtn ihat there is a consimctbn lentling agency fw the
perfortnance o( the �ork far v.hich Ihis pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Address:
Sipnature Date
OWNER-BUILDER DECLARATIONS:
I hereby affirm that untler penalty of perjury Iha� I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason �Sec. 7031.5,
Business antl Professions Code: Any city or counry which requires a permit to
construct, alter, improve, Oemolish, or repair any struclure, prior lo ils
issuance, also requires the applicant for such permit lo (le a signed statement
t�at he or she is licensetl pursuant lo the provisions of the Contractors
License Law (Chaprer 9(commencing with Section 7000) of Division 3 of the
Business antl Professions Code) or that he or she is exempt therefrom and
the basis for the allegetl exemption. Any violation of Section 7031.5 by any
applicaN (or a permit subjects the applicant ro a civil penalry of not more than
fve hundred dollars (3500).):
��� I, as owner of �he propetly, or my employees with wages as their sole
compensation, WILL DO THE WORK, and the structure is not intended or
oKered !or sale (Sec. 7044, Business and Pro(essions Code: The Contractors
License Law does not apply lo an owner of property who builds or improves
lhereon, and who does such work himself or herself or through his or her ovm
empbyees, provided Ihat such improvements are not intended or offered for
sale. If, however, the builtling or improvement is sold within one year of
wmpletion, the owner-builder will have the burtlen of proving that he or she
did not build or improve for purpose of sale.).
❑ I, as ovmer o( the property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and
Professions Code: The cont2ctors License Law dces not apply to an ovmer of
property who builds or improves thereon, and who wntracts fw such project with
a cmtractw�s) license pursuant to the Contractors License Laws.).
❑ I am eaempt under sec.
Business and Professions Code !or this reason:
Signature�-�-- �a�e� �I�
]OS)<6�Y0)) "
Owner ID verifed by tlriver's license. Yes ❑ No
Driver's License No. Expires: �— ZZ —f 3
�
Verification of Ownership by (type of document, i.e. - propehy tax hill or deed):
DIVISION OF INDUS7RIAL SAFETV PERMI7 CERTIFICATION: �
❑ I hereby certify ihat no excavation frve (5) or more (eet in depth into wfiich a
person is required to descend will be made in connec[bn wi�h work au[horized
by this permit, and that no building stmcture, scaffolding, falsework, or demolition
or dismantling thereof, will be more than thirty-six (36) (ee[ high. (Chap. 32, Grp
2, Fvt 2, Sec. 341, Title 8, Califomia Administ2live Code).
❑ As owner-builder, I will not employ anyone to do work which woula
require a permit /rom the Division of Industnal Safery, as notetl above, unless
such person has a permit to do such work (rom the division.
Applicant's $ignalure
Division of Industrial Safety Permit Number: _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will Ihe applicant or present or fuWre building occupant need to file and
certify a Business Plan tor emergency response to release or threatened
release of a hazardous malerial? ❑ Yes ❑ No
(Section 25505 of the Califomia Healih and Sa(ety Code requires, with some
exceptions, tha[ 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 Quanti�y of hazardous materials equal to or greater than a weight ot
500 pounds, or a volume of 55 gallons, or 200 cubic /eet of compressed gas
at standard temperature and pressure).
2. Does or will Ihe appliwnt or present or fuWre building occupant need to file
a registration (orm for acutety hazardous matenals? ❑ Yes ❑ No
(Seclion 25533 of the Califomia Health and Satery Cotle, with some
exceptions, requires registration with the Costa Mesa Fire Oepartment by
each business which at any one time has on hand a quantity o( acutely
hazardous materials equal lo or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic teet of compressed gas at standartl
temperaNre and pressure).
3. Does or will the applicant or present or (uture building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous matenals)? � Yes ❑ No
(Seclion 25534 of the California Health and SaFery Code provides that the
Costa Mesa Fire Departmenl may require Ihe preparation, certi(cation and
filing with the Fire Department of an RMPP by businesses which are required
to register awtely hazartlous matenals with the Fire Depariment.
4. I( an RMPP is presently required, has Section 25534 of [he Cali(ornia
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or vnll the applicaN or present or (uture huilding occupant require for
the vrork which is the subject of this application a permit for such construction
or modi(cation from lhe South Coast Air Qualiry hlanagement Dislrict or from
any other air Oollution control distnct or agency? ❑ Yes ❑ No
�Section 658502 of the Califomia Govemment Code requires that the requested
information be fumished on applications for non-residential building permits).
6. Will any part of lhe (acility to be constructed under this permit be within
1000 feet trom [he outer boundaries of a school? ❑ Yes ❑ No
Qf'yes", the (acili[y must meet [he requirement of Sections 25534 and 42303
of the Cali(omia Health and Safery Code).
7. If a pertnit (rom the SoWh Coast Air Qualiry Management District or o�her
air polWtion control district or agency is required for the vrork which is the
subject of Ihis application, have all of the disclosures prescribed by Califomia
Health antl Safety Code Section 42303 been made? ❑ Yes ❑ No
8. Qf'yes", attach certifcate of wmpliance fmm the appropriate air pollution
con[rol offcer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
in(ortnation given above is covect I agree ro compty wiih all state laws and
ciry ordinances regarding Hazardous Materials and Emissions.
SlgnaWre Dale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify untler penalry of perjury that I have read this application and state that
the information given is covecL I agree to comply with all s[ate laws and ciry
ordinances relating to building construction, and authorize representatives of
the City of C a Mesa to enter upon the above-described property for
inspec�ion p ses. I agree not to occupy or allow occupancy o( any building
authorize y is permit until ia �nspection.
li%I�„✓1 .,�---� m - � r��
SignaWreofCepalOvmeqs�,� Dale.,.7
An41wAu1�onzeEAppliWnl Date
,/�' =� �--�
-�
�.-�-�..1
Costa Mesa
City of Costa �Vlesa BuiCding 1�ivision
77 Fair Drive, Costa Mesa, CA 92626
714-754-5273 / Fax 714-754-4856
OWNER BUILDER VERIFICATION
Permit # �� p=��� r �
Disclosures 8� Forms for Owner- Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has�¢ en submitted in your name listing yourself as the builder of the
property improvements specified at 2`/� �i �Gl YUJIni ,�✓•
We are providing you with an Owner-Builder Acknowledgmea� and Information Verification Form to make you
aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of
each provision, signed, and returned this form to us at our official address indicated. An agent of the
owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting
authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIR\ECTIONS: Read and initial each statement below to signify you understand or verify this information.
t�_" 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and
material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any
injuries sustained by an unlicensed person and his or her employees while working on my property. My
homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder
and am aware of the limits of my insurance coverage for injuries to workers on my property.
�=�2. I understand building permits are not required to be signed by property owners unless they are
responsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
C- V 3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that
I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his
or her name instead of my own.
�4. I understand Contractors are required by law to be licensed and bonded in California and to list their
license numbers on permits and contracts.
�5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors,
and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may
be considered an "employer" under state and federal law.
C"� 6. I understand if I am considered an "employer" under state and federal law, I must register with the state
and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and
contribute to unemployment compensation for each "employee." I also understand my failure to abide by these
laws may subject me to serious financial risk.
C�� 7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed
by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of
the work is performed under contract with a licensed general building Contractor.
3148-30 CALBO Jan 1, 2009 OB Packet template 1 of 2
�
L� 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable
for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent
construction defects in the workmanship or materials.
(, '� 9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit
Payments, and the California Division of Industrial Accidents. I also understand I may contact the California
Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information
about licensed contractors.
C'� �10. I am aware of and conseni to an Owner-Builder building permit applied ior in my name, and understand
that I am the party le�ally and�nancially responsible for proposed construction activity at the following address:
/� v
C. •� 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will
abide by all applicable laws and requirements that govern Owner-Builders as well as employers.
(, � u% �12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the
public. If you contract with someone who does not have a license, the Contractors' State License Board may be
unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against
unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed
Contractor or employee of that individual or firm is injured while working on your property, you may be held
liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible
for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance cqverage.
Before a building permit can be issued, this form must be completed and signed by the property owner
and returned to the agency responsible for issuing the permit. Note: A copy of the property ownei's
driver's /icense, form notarizati , or other verification acceptable to the agency is required to be
presented when the permit is � ed to verify he roperty owner's signature.
Signature of property owner Date: �� 3'—�
Note: The following Authorization Form is required to be completed by the property owner only when
designating an agent of the property owner to apply for a construction permit for the Owner-Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I
hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents
necessary to obtain an Owner-Builder Permit for my project, .
Scope of Construction Project (or Description of Work): _
Project Location or Address: , _
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled
out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form
notarization, or other verificstion acceptable to the agency is required to be presented when the permit is issued
to verify fire property owner's signature.
Property O�vner's Signature:
Date:
3148-30 CALBO Jan 1, 2009 OB Packet template 2 Of 2
�OT �Z TRACT 3940
1��:�C�
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 9f7 COBTA MEBA. CALIFORNIA
For Applieanf fo Fill In Completely
' TYPE OR PRINT
BUILDING
ADDRESS � � � �.�
� COSTA MESA. CALIF NIA
OWNER KO�CO CONSTRUCTION CO. INC.
MAIL '__ _ "_ '
TEL.
Isize �// r.,�,.�.,. —.. INO.OP
1 86TlACK LIN[ IROM 'J/ �
� I LEFT / l3 4 I RIGHT �D' �„
DESCRIPTION OF WORK
EXTERIOR WALL IROOF
COVERING STUCC cOVERING, i
USH OP BUIL�ING AND WORK TO BE PERFORMED
SINGLE FAMILY RESIDENCE
ATT�HCED GARAGE �!1%�
PIRE
ZONE
APPROVED
�eow�
��E RECEIVED
dul. � i tssi �j Crr
FINANCE DEPT.
CITY QF COS�A MESA
APPLICATION FOR PERMIT
BUILDING
For Offiae Use Only
necs�rt Ho. .1 `Rrggw�lKo.
Q- 7 )
BY I DAiE REC61VlD I DATC I63UED
COSTA MESA. CALIFORNIA
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APPROVED w ��.
— BY
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1 X81i[GY ACKNOWLEG6¢ THAT 1 HAVB RGD TX19 APPLIGTION � �
TXE AM NT BHOWN UND¢P VALt1ATION 18 FOR THE
AND BiATB THAT TN8 ABOVH 18 WRRIIGT AtID I�GPBE TO COM- pUPP08E OF EBTABLI8H�N0 A P¢RMIT FE6 oNLY.
PLY WITH ALL GITY OIlDINANC68 AND BTAT¢ LAWB ftB6ULATINO
� eu1LDIN0 CONBTRj ON. VALUATION a ./ K�
81GNATURH OF � � ' PERMIT FEE $. J�`'
PERMITCE 'J
� ' S/' /' � %� �j PLAN CNECK $ �/ �
AUTHORIZED AGENT �r <� .c"/ � -
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