HomeMy WebLinkAbout119 FLOWER ST - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesaL9CTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address:
119 FLOWER ST
Status: ISSUED
Suite No
Vicinity:
ELECTRICAL METER
- -
Applied: 09/28/2005
Issued: 09/28/2005
-- ISSUE FEE z=
- $23.50-
j4J i L�
Temp service test '
Parcel Nunmber:
42545215
Res. a/c package
--$0.00.
- - - -
New Res (1-2 units) ' „
$0.00-
DA's
New Res (3+__units)_:-$0.00
Applicant:
STONER, BARBARA
Pool /Spa
- $0.00 -
Address:
119 FLOWER STREET
_
ISSUED BY:
Recept Outlets
- $0.00. ,
',.Phone: '.949-515-9009. •:
Switches " -
- $0.00, .''�
COSTA MESA, CA
- Zip' - 92627
- $0.00���;•':
0
Res'Appl
$0.00.`.
0
Service to 200a -''
$30.50
1
Service to 1000a
' -
Sc
UPGRADE ELECTRICAL METER FOR S
F
- -
Quantity.
-- ISSUE FEE z=
- $23.50-
- -
Temp service test '
=$0.00
'- $0.00 -
Res. a/c package
--$0.00.
- - - -
New Res (1-2 units) ' „
$0.00-
0
New Res (3+__units)_:-$0.00
_
0
Pool /Spa
- $0.00 -
a ,.. 0
Lighting Fixts-
$0.00
.-0<--
Recept Outlets
- $0.00. ,
- -0
Switches " -
- $0.00, .''�
0
Non Res Appl
- $0.00���;•':
0
Res'Appl
$0.00.`.
0
Service to 200a -''
$30.50
1
Service to 1000a
- $0.00 <_-.'
0
Service over 1000a
'$0.00
0
Motors to
$0.00
0 -
,lhp
Motors to 10hp
-'-$0.00
0 - -
Motors to50hp!
$0.00
;01-
Motors to 1 00h
- $0.00
0
Motors over 100hp
$0.00
30
Communication drops _
'r `$0.00
- 0-' -
Sub panel to 200a
"`$0.00--,
0.-'
Pole Light Pkg
$0.00
0
Sign Circuits
$0 00 `-'
o.,
Temp Pwr Pole
=,$0-00 =,
0
Intermed Pole
'r' $0.00
�`. 0
OPE OF PERMIT
FD.
EE SUMMARY,
- -
:Quantity
Temp Dist System /,Lighting
- $0.00.
0
Busway /100 ft:.:.
'- $0.00 -
-. 0
- • -"Standing Section-' "°-'
$0.00 -.
0 - -
Misc Electrical Equipment
$0.00
01
Transformers up to'l kva/kw
. $0,00. -
0
......... -...... up to 10 kva/kw = - --
$0:00= --
0
................up to 50 kva/kw ',
$0 00, "-
0'.
.................up to 100 kva/kw
$0,00'. -,
. 0� ..
..................over 100 kva/kw
$0 00 `
„ O '�
Low Voltage Equipment
-;$0.00 '
- 0,
Low Volt Wiring System / Ckt
$0.00 :'
0�
Misc. Conduit
$0:00
Q<<
- Misc. Conductor
$0.00
0 -
'- Circus ( gen or ride)
$0.00` `
- 0
Circus (meoh ride or lights)
$0.00
0
- ,Christmas TreeStand$0.00
sk'
0..
,Fireworks Stand �,,
- $0.00
0
,Other Electrical': Fee -
- $0.00
-
Investigation F66'-
$0.00
-'Plan Check Fee--
-$0.00
.
-.Reinspection Fee
$0.00,
TOTAL CALCULATED FEES
..$54.00
'
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
244646 (6/00)
DECLARAMNS
WORKERS' COMPENSATION DECLARATION: '
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carter and policy number are:
Carder: Policy Number:
r(Thisse need not be completed it a permit is valued atone hundred dollars ($100) or less.)
that in the pert n e f e work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
nsatlon laws oP; la ntl rea that should become subject to the workers'compensation provision f Section 3700 of the Labor Cotle, I shell fortM1with
with these pro to a
Applicant Signature:^-- (Dater' �V�O
WARNING: FAILURE TO SECUR COMPENSATIIXN COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRI NALPENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOL -ARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full
force and effect. Lic. k 1' Class q
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-BUILDERATIONS:
I hereby affirm that airy 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 c ch rlov-eimp
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 stat em at hIs IicanSed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Pro lessl Cadehe o 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 pf not live hundred dollars ($500).):
❑ I, as owner of the property, wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions C ractors-'nse.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 ass,
,That such improvements are not intentled or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner ilderburden of proving that he or she did not build or improve for purpose M sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONWITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply tf 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: IDate:
Owner ID verified by drivers 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:
❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
parnit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
............... _........ _. _.......................... _...............................................,.................................................................................................................................................................................................................................................................................
2 Does or will the applicant or present or future building Occupant need to file a registration form for acutely hazardous materials? 0 a ❑ 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).
....._......__ ......... ............... __..............._........................................ I................................................................................................................................................................................................................................................
3 Does or will theappplicant or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ 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.
...............................................................................................................2..............................................................................feit...............................................................................................................................................................................
4 If en RMPP Is presently required, has Section 25534 of the California Health antl Safety Code been fully complied withl ❑Ves ❑ 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 eppermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or age I Yes LJ No
(Section 65850.2 of the California Govemmant Code requires that the requested information be furnished on applications for non-residential building permits).
.................................................................................................................................................................................................................................__......................................................................................................................................................
e Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Ves ❑ No
(If'jee, 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 Qualify Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
........._................................................. ............................................. ..................................... ................................................................ .......................................................................... ......................................................... ............... I..........................
B (If yes", attach certificate of compliance frorn 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 sta we and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property r ins ti n urposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Si t O I n s) (4 ?S,
(J ` ni-- Date
AlAOrothtfrized Applicant Date.,a
CODE 0. INSPECTION TYPE PLTE INTRIALS CODE INSPECTION TYPE Deg DNTITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Roof 210 Final Electrical
201 Final BlocWRelaining 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 BuildingfOccupancy
r�
OWNER -BUILDER
VERIFICATION
Address: Q 1 'How (04 1 r wl Permit #:
A city or county, which is required to give notice pursuant to Section 19830, shall attach to such notice, and, as
a condition precedent to issuing a building permit, require the completion and require the return of, an owner -
builder verification.
Attention Property Owner:
An `owner -builder' building permit has been applied for in your name and bearing your signature.
Please complete and return this information in the envelope provided at your earliest opportunity to avoid
unnecessary delay in processing and issuing your building permit. No building permit will be issued until this
verification is received.
1. I personally plan to provrd e major labor and materials for construction of the proposed
property improvement. \'Yves, ❑ No
2. I (have/have not) V C/ signed an application for a building permit for
the proposed work. _
3. I have cont racte with the following so (firm) to provide the proposed construction:
Name t'k
Address City
Phone Wk Contractor's Lic. No.
4. I plan to provide portions of the work, but I have hired the following person to coordinate,
supervise and provide the major work:
Name
Address City
Phone ( ) Contractor's Lic. No.
5. I will provide some of the work but I have contracted (hired) the following persons to
provide the work indicated:
Name Address Phone Type of Work
14246 (Rev. 11/04
DECLARATION OF AUTHORITY
FOR AGENTS OF PROPERTY OWNER
TO APPLY FOR PERMITS
Street Address'
Bldg, Permit #
This Permit#
AP Number.
t, 1(we), Jam ftim— , declare that I am the Owner of TRIe of the above
rafarenCed real property, and that I (we) hereby authorize:
Name: Telephone Number -)q
straot Address: —m Row sk
M
to obtain permits In my behalf, as owner/builder, for
at the above referenced property.
Zip:
2. Should any person become an employee engageo in the Improvement of the property, I (we) shall Immediately protide Workers
Compensation Insurance coverage and muse a certificate of that coverage to be filed with the Building Division of the City of Costa
Mesa, as required by state of Callfomis laws.
3. As owneribuilder in fad, 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 dr officers harmless from any claim resulting in damage or
personal Wary to myself or any ocher pasties as a result of w * authorized by the permits from the City of Costa Mesa,
5. 1 dedare under the penalty of perjury that the foregoing Is Wa and correct.
'
6reculad this day of 20 vJ , at UJB ►Y K ,California.
i' •1'4 4 ,O)o
WX
Note: This eu[honZ01 on ddes riot grant authorization to Won the wo* its owner,
it solely provides for limited power of afhtmey m secure this permit in any behalf.
0)78-06 (m11NR)
COO 12T'd 068'OW 09 TRRR hrR RWd6T:2 or,S002'82'd3Siar,
November 21. 2008
Ary OF COSTA MESA
P.O. BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 92628-1200
DEVELOPMENT SERVICES DEPARTMENT
BUILDING DIVISION
COURTESY NOTICE OF PERMIT EXPIRATION
Daniel Maxam
1929 Tustin Avenue
Costa Mesa, CA 92627-2808
PERMIT NUMBERS: `'E05-01018
FOR: Upgrade Electrical Meter
PROJECT ADDRESS: 119 Flower St., Costa Mesa, CA
Our records indicate the above listed permits 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 the last
inspection for the project.
Our records do not show an inspection for these permits within the last 180 days nor have
they had an approved final inspection. If you have a signed inspection card showing that an
inspection was made within 180 days, or that the final inspection was approved, please
contact this office so we may correct our records. If you do not have an approved final
inspection, your permits will expire on December 1, 2008. Additional fees will be required to
finalize expired permits.
Requesting an inspection—If you need to request an inspection, please call our Inspection
Request Line at 714-754-5626.
Requesting an extension—If you wish to request an extension, requests must be made in
writing addressed to Ed Petros, Chief of Inspection, at the above address, detailing
circumstances and listing an estimated date of completion.
If you have any questions, please contact the Building Division at 714-754-5273, between
8:00 a.m. and 4:30 p.m., and a staff member will assist you. The accuracy of records
affecting your property is our goal and we appreciate your working with us to resolve this
matter.
Sincerely
6011 ,
Barbara J. Zwart
Office Specialist II
Building Division (714) 754-5273 • Code Enforcement (714) 754-5623 • Planning Division (714) 754-5245
FAX (714) 7544856 • TDD(714)754-5244 • vf..w.ci. costa -mesa .ca.us
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
ELECTRICAL PERMIT
Job Address: 119 FLOWER ST
Suite No
Vicinity:
Parcel Nunmber: 42545215
Applicant: CHARTER, RONALD
Address:
Owner: WILLEMS, LISA
Address 119 FLOWER ST
Contractor:
Address:
COSTA MESA, CA
Phone: 949-689-9700
Zip:
Phone:
Zip: 92627
Phone:
Zip:
License:
SCOPE OF PERMIT
SERVICE UPGRADE TO 200 AMPS.
77 FAIR DRIVE, COSTA MESA, CA 92626
Gcrr-P-E o
D
Applied: 12/27/2000
Issued: 12/27/200(
ISSUED BY:
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
2446-46(6/00)
FEE SUMMARY
Quantity
Quantity
ISSUE FEE
$23.50
Temp Dist System / Lighting
$0.00 0
Temp service test
$0.00
Busway /100 R
$0.00 0
Res. a/c package
$0.00
Standing Section
$0.00 0
New Res (1-2 units)
$0.00
0
Misc Electrical Equipment
$0.00 0
New Res (3+units)
$0.00
0
Transformers up to 1 kva/kw
$0.00 0
Pool / Spa
$0.00
0
................ up to 10 kva/kw
$0.00 0
Lighting Fixts
$0.00
0
.................up to 50 kva/kw
$0.00 0
Recept Outlets
$0.00
0
.................up to 100 kva/kw
$0.00 0
Switches
$0.00
0
..................over 100-kva/kw
$0.00 0
Non Res Appl
$0.00
0
Low Voltage Equipment
$0.00 0
Res Appl
$0.00
0
Low Volt Wiring System / Ckt
$0.00 0
Service to 200a
$30.50
1
Misc. Conduit
$0.00 0
Service to 1000a
$0.00
0
Misc. Conductor
$0.00 0
Service over 1000a
$0.00
0
Circus ( gen or ride)
$0.00 0
Motors to 1 hp
$0.00
0
Circus (mech ride or lights)
$0.00 0
Motors to 10hp
$0.00
0
Christmas Tree Stand
$0.00 0
Motors to 50hp
$0.00
0
Fireworks Stand
$0.00 0
Motors to 1 00h
$0.00
0
Other Electrical Fee
$0.00
Motors over 100hp
$0.00
0
Communication drops
$0.00
0
Investigation Fee
$0.00
Sub panel to 200a
$0.00
0
Plan Check Fee
$0.00
Pole Light Pkg
$0.00
0
Reinspection Fee
$0.00
Sign Circuits
$0.00
0
Temp Pwr Pole
$0.00
0
TOTAL CALCULATED FEES
$54.00
Intermed Pole
$0.00
0
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
2446-46(6/00)
I
ECLARATIONS
WORKERS' COMPENSATION DECLARATION: '
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carrier and policy number are:
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 CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full
force and effect. Uc. N Claes k
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: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
Id 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 contractods)
license pursuant to thelContractors License Laws.).
❑ I am ex t and c.11 R K- tiV
p f "-- Business and Professions Code for this reason:
Signatu e: '� ,. -!Y "z+ +D. liDate: -7 Ao
Owner ID verified by driver's license.es,T, [INo Drivers License o. Expires:
V AAl
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 B, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
............................................................................................................................................................................................................................................................................................................................................................................................
2 Does or will the 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 lest o1
compressed gas at standard temperature and pressure).
...................................................................................................... ... ................................................ ............................. ............................................................................................. -................. ................................................................. I..................
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.
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4 If an RMPP is presently required, has Section 25534 of the California Health and Satery Code been fully complietl with? [3 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 agertnit for such construction or modificationfrom 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).
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8 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No
(If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
W.W. ..........................................................................................................
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
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B (If yes', attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with aill state jaws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
abov - escnbed g2dy 1 action s. I agree not to occupy or allow occupancy of any building authorized by this permit yntil final inspection.
Signature Of Legal Owner(s) Dat
And/Or Authorized Applicant Date
CODE If INSPECTION TYPE INTITIAL CODE1 INSPECTIONTNPE Ifs
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final BuildingrOccupancy