HomeMy WebLinkAbout1569 AMBERLEAF - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address:
1569 AMBERLEAF
FEE SUMMARY
Status: ISSUED
Suite No
Quantity
Applied: 01/25/2001
Vicinity:
PLAN 3
$23.50
Issued: 02/07/2001
Parcel Nunmber:
TPN00057
Temp service test
$0.00
Applicant:
PHILIPP, ROLAND
0
Res. a/c package
ISSUED BY:
Address:
1565 W MAC ARTHUR
$0.00
0
New Res (1-2 units)
$166.43
COSTA MESA, CA
Phone:
714-668-4300
0
New Res (3+units)
$0.00
Zip:
92626
$0.00
Owner:
STANDARD PACIFIC HOMES
$0.00
_ - 0
................up to 10 kva/kw -
Address
1565 W MAC ARTHUR
Lighting Fixts
$2.20
2
.................up to 50 kva/kw
COSTA MESA, CA
Phone:
714-668-4300
$3.30
3
.................up to 100 kva/kw
Zip:
92626
Switches.
Contractor:
OWNER -BUILDER
..................over 100 kva/kw
$0.00'
,10
Address:
$0.000
Low Voltage Equipment
$0.00
110
Res Appl
Phone:
0
Low Volt Wiring System / Ckt
,$0.00
0'
Zip:
$0.00
0
Misc. Conduit
$0.00
License:
0
$0.00
SCOPE OF PERMIT
CONSTRUCT NEW SFR PLAN 3 FOR STANDARD PACIFIC HOMES: 2972SF LIVING, 579SF GARAGE,
20SF COVERED ENTRY, 133SF PATIO.
1 NEW RES (1 UNIT), 2 LIFHT FIXTURES, 3 OUTLETS, 2 SWITCHES, 1 MOTOR TO 1 HP. REF:
B01-00098
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
P""A (NMI
FEE SUMMARY
Quantity
Quantity
ISSUE FEE
$23.50
Temp Dist System / Lighting
$0.00
0
Temp service test
$0.00
-Busway /100 ft
$0.00
0
Res. a/c package
$0.00
Standing Section
$0.00
0
New Res (1-2 units)
$166.43
2972
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
$2.20
2
.................up to 50 kva/kw
$0.00
0
Recept Outlets
$3.30
3
.................up to 100 kva/kw
$0.00
0
Switches.
1 ". $2.20
2
..................over 100 kva/kw
$0.00'
,10
Non Res Appl
$0.000
Low Voltage Equipment
$0.00
110
Res Appl
$0.00
0
Low Volt Wiring System / Ckt
,$0.00
0'
Service to 200a
$0.00
0
Misc. Conduit
$0.00
0
Service to 1000a
$0.00
0
Misc. Conductor
$0.00
0
Service over 1000a
$0.00
0
Circus ( gen or ride)
$0.00
0
Motors to 1 hp
$4.75
1
Circus (mech ride or lights)
$0.00
0
Motors to 10hp
$0.00
0
Christmas Tree Stand
$0.00
0
Motors to 50hp
$0.00
0
Fireworks Stand
$0.00
0
Motors to 100hp
$0.00
0
Other Electrical Fee
$0.00
Motors over 100hp
$0.00
0
Communication drops
$0.00
0
Investigation Fee
$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
$202.38
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
P""A (NMI
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the pedomlance of the
work for which this permit is issued.
❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed i/ 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 3706OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
force and effect. Lia q Class q
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade).
Lander's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant fora 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
ode: 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 toc. Bass and Professions Code for this reason:
Signature: Date: Z Z--
Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or dead):
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, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) teat high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Cade).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety 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).
.............................................. .................................................................. -............................................................................................. ................ ......................................................................................... .......................................... 1111......................
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).
............................................................................................................................................................................................................................................................................................................................................................11..........11.................
3 Dces 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..........f .anR.M......................................................................................................................................................................................................- ................................................................ ................................................................
PPis
presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
.......................................................................................... .............................................. -..............................................................................................................................................................I............................. ..........................
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 emit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
...........................................................................................................................................................................................................................................................................................................................................................................................
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ NO
(if -yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
................................................................. .................................. ........................................-............................................................ .......................................... .......................... ............................. .................................................. ................................
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
............................................................................................................................................................................................................................................................................................................................................................................................
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 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. 1 agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
' natur 1 Le (s) I Dat
And/Or Authorized Applicant F Dale
CODE 1. INSPECTION TYPE DATEINTRIALS CODES INSPECTION TYPE DAM IKTMAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical VL
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 1569 AMBERLEAF Status: ISSUED
Suite: L07-llJ Applied: 01/25/2001
Vicinity: PLAN 3 Issued: 02/13/2001
Parcel Number: TPN00057 Zoning:
Applicant: PHILIPP, ROLAND ISSUED BY:
Address: 1565 W MAC ARTHUR
COSTA MESA, CA Phone: 714-668-4300
Zip: 92626
Owner: STANDARD PACIFIC HOMES
Address 1565 W MAC ARTHUR
COSTA MESA, CA Phone: 714-6684300
Zip: 92626
Contractor: OWNER -BUILDER
Address:
Phone:
Zip: License: 0
Arch : BASSENIAN LAGONI Eng:
Address: 2031 ORCHARD OR Address:
STE 100 Phone: 949-553-9100 Phone:
NEWPORT BEACH, CA
Zip: 92660 License: License:
SCOPE OF PERMIT
CONSTRUCT NEW SFR PLAN 3 FOR STANDARD PACIFIC HOMES: 2972SF LIVING, 579SF GARAGE, 20SF COVERED
ENTRY AND 133SF PATIO.
REF: B00-01537
NOTES:
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
i
2"6ae isrom
FEE SUMMARY
Plan Check:
$316.19
Calc Valuation: $269,922.26
Permit:
$1,945.75
Claim Valuation: $0.00
SMIP Res:
$26.99
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total:
$2,288.93
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front 16- 0
Rear 21-0 Left 5-0
Right 5-0
ACCESSORY
Front 0-0
Rear 0-0 Left 0-0
Right 0-0
PARKING
Existing: 0
Required: 3 Proposed: 3
NOTES:
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
i
2"6ae isrom
;~N -
DECLAgATIONS
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 LaborCode, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars ($100) or less.)
❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SWILL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DO -1 -ARE (5100,000), 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. if Class if
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil 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 Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
Oa -1, 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.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes No Driver's License No. xpires:
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, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
34'.. Title 8, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
............................................................................................................................................................................................................................................................................................................................................................................................
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ 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 Califomia 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 ayPerma for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? _1 Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential builtling permits).
...........................................................................................................................................................................................................................................................................................................................................................................................
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
..................................................................................... .................... ......................................... -............................ .......................... ............................ ............................................................. ................................ ...................... ...................... I ...........
.
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 AUIHORIZATION. 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,
a r Ot L I n ) Dat
n A �- 2 Z D 1
And/Or Authorized Applicant V f Odle
CODE t. INSPECTION TYPE INTITIAL CODE 1 INSPECTION TYPE QAM INTI IAL
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Root 210 Final Electrical
201 Final Block/Retaining 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 Q 7.t ar
FINAL GROING CERTIFICATION
Project Address: 16:1 4'S 1A4L'AS
Lot Number. t t-CtNKo t 9 (t H i Co -K-ytit4&" 115CP:;,S z
Permit Number: Gr On — 2` 0.57—
By Civil Engineer:
I certify to the satisfactory completion of grading in accordance with the approved plans,
specifications, local and state codes. All drainage devices required by the grading permit,
grading plan and grading ordinance have been installed. Mequate.provisions have been made
for drainage of surface water from each building site.
The minimums are:
2% Fall from structures within 5 feet from exterior walls.
1% Fall for asphalt surfaces and landscaped areas.
0.5% Fall for concrete surfaces to approved disposal areas.
The final monuments as shown on the recorded tract map were set. All final grading.eleva.
tions are within ± 1/10 of the designedelevation
Supervising Civil Engineer Reg. No. 3!4"18
(Signature)
Datr _14911-5 1oI
Cq LEAD �. A[ eTn"
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 I -AIH UHIVC, UUJ I A MCJA, UA eZ102ti
MECHANICAL PERMIT
Job Address: 1569 AMBERLEAF
Suite No
Vicinity: PLAN 3
Parcel Number: TPN00057
Applicant: PHILIPP, ROLAND
Address: 1565 W MAC ARTHUR
COSTA MESA, CA
Owner: STANDARD PACIFIC HOMES
Address: 1565 W MAC ARTHUR
COSTA MESA, CA
Contractor: OWNER -BUILDER
Address:
Arch / Eng :
Address:
ISSUED BY:
Phone: 714-668-4300
Zip: 92626
Phone: 714-668-4300
Zip: 92626
Phone:
Zip:
License: 0
Phone:
Zip:
License:
Status: ISSUED
Applied: 01/26/2001
Issued: 02/07/2001
SCOPE OF PERMIT
CONSTRUCT NEW SFR PLAN 3 FOR STANDARD PACIFIC HOMES: 2972SF LIVING, 579SF
GARAGE, 20SF COVERED ENTRY, 133SF PATIO.
2 FAU <1001K BTU, 1 FACTORY FIREPLACE, 1 HOOD W/MECH EXHAUST, 1 VENT FAN/SINGLE
DUCT, 2 COMPRESSORS UP TO 3HP/100K BTU. REF: B01-00096
TOTAL CALCULATED FEES $111.05
NOTICE: The work authorized py 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
'.d A'PINI
FEE SUMMARY
Quantity
Quantity
ISSUE FEE
$23.50
Repair / Alt Absorbtion Unit
$0.00
0
Inst FAU <100 k BTU
$29.60-
2
Repair / Alt Refrigeration Unit
$0.00,
0
Inst FAU >100 k BTU
$0.00
0
Ventillation System -
$0.00;
0
Repair/Alt Cooling/Heat
$0.00
0
Evaporative Cooler _ -
$0.00'
0
Inst / Rep. Recess Wall Htr
' $0.00.
0
Commercial Incinerator -
$0.00
0
Refrig Sys <100 k BTU
$0.00
0
Domestic Incinerator
- $0.00
0
Refrig Sys >100 k BTU -
$0.00
0
Compressors /Absorption Systems
Gas Piping
$0.00
0
Up to 3 hp / 100k BTU
$29.40
2
Factory Fireplace
$10.65
1
3 To 15 hp / 500 k BTU
$0.00
0
Hood w/Mech Exhaust
$10.65
1
15 To 30 hp / 1,000 k BTU
$0.00
0
VAV Box
$0.00
0
30 To 50 hp / 1,750 k BTU -
$0.00
0
Vent Fan / Single Duct
$7.25
1
Over 50 hp / Over 1,750 BTU
$0.00
0
Appliance
$0.00
0
Boilers
Fire Dampers
$0.00
0
Up to 3 hp
$0.00
0
Smoke Dampers
$0.00
0
3 To 15 hp
$0.00
0
Inst or Relocate Appl Vent
$0.00
0
15 to 30 hp
$0.00
0
Air Handlers < 10000cfm
$0.00
0
30 to 50 hp
$0.00
0
Air Handlers > 10000ofm
$0.00
0
Over 50 hp
$0.00
0
Floor Furnace
$0.00
0
Other Mechanical Fee
Floor or Suspend Heater
$0.00
0
Investigation Fee
$0.00
Plan Check Fee
$0.00
Reinspection Fee
$0.00
TOTAL CALCULATED FEES $111.05
NOTICE: The work authorized py 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
'.d A'PINI
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars ($100) or less.)
❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES A$ PROVIDED FOR IN SECTION 3106 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. a Class a
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code),
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 Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exam p oder s Business and Professions Code for this reason:
Signature:—� Date: --L,)
%
Owner ID verified by drivers license. Yes C1 N8 Driver's License No. xpires:
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.
34'.. Title 8, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
............................................................................................................................................................................................................................................................................................................................................................................................
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ 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).
............................................. ............. ................................. .......................................................................................................................... .... ................ ................... ....................................................................................... ..................... 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.
............................................................................................................................................................................................................................................................................................................................................................................................
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 ermit for such construction or modification
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).
.......................................................................................................................................................................................................................................................................................................................................................................................
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
............................................................................................................................................................................................................................................................................................................................................................................................
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
...............................................................................................................................................................................................................................................................................................................................................
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 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.
netOfp`ggl O r(s) ry- ^/ Z/Z tate D
And/Orr Authorized Applicant/ Dae /
CODE 0. INSPECTION TYPE Qom' IIHTTTITIAL CODES INSPECTIONTYPE DATE IN AL
1616 Fixed System Final Fire Prevention 206 Final Mechanical 10 9 01
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us // r -Ain univr=, �Wo v A McaA, t A acozo
PLUMBING PERMIT
Job Address: 1569 AMBERLEAF
Suite No
Vicinity: PLAN 3
Parcel Nunmber: TPN00057
Applicant: PHILIPP, ROLAND
Address: 1565 W MAC ARTHUR
COSTA MESA, CA
Owner: STANDARD PACIFIC HOMES
Address 1565 W MAC ARTHUR
COSTA MESA, CA
Contractor: OWNER -BUILDER
Address:
Arch / Eng :
Address:
Status: ISSUED
Applied: 01/26/2001
Issued: 02/07/2001
ISSUED BY:
Phone: 714-668-4300
Zip: 92626
Phone: 714-668-4300
Zip: 92626
Phone:
Zip:
License: 0
Phone:
Zip:
License:
SCOPE OF PERMIT
CONSTRUCT NEW SFR PLAN 3 FOR STANDARD PACIFIC HOMES: 2972SF LIVING, 579SF GARAGE,
20SF COVERED ENTRY, 133SF PATIO. 3 BATHRUBS, 1 DISHWASHER, 1 EXPANSION TANK, 1 GAS
(1-4 OUTLETS), 2 GAS OUTLETS (OVER4), 1 LAUNDRY TUBNVASHER, 1 PRESSURE REGULATOR, 1
SEWER CONNECT, 1 SHOWER, 1 KITCHEN SINK, 1 SERVICE/MOP SINK, 1 WASH BASIN, 2 WASH
BASIN SETS, 3 WATER CLOSETS, 1 WiER HEATER, 1 WATER SERVICE. .-
REF: B01-00098
QTY
FEE SUMMARY
AMT
ISSUE FEE
$23.50
Backflow irrigation
$0.00
Backflow Prevenler
$0.00
Bathtub
$29.40
Clarifier System
$0.00
Connect (Ice,Soda,etc)
$0.00
Dental Units
$0.00
Dishwasher
$9.80
Drain, Floor
$0.00
Drain, Rainwater
$0.00
Drain, Roof
$0.00
Drinking Fountain
$0.00
Expansion Tank
$9.80
Gas Earthquake Valve
$0.00
Gas (1-0 outlets)
$6.15
Gas (Over 4 outlets)
$2.20
Gas Repipe
$0.00
Gas Service
$0.00
Interceptors (Grease, Oil)
$0.00
QTY
FEE SUMMARY
-
AMT
QTY -
/
AMT
QTY
Laundry Tub / Washer
$9.80
1
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
$9.80
1
Urinal
$0.00
0
Process Piping (per 10 ft)
$0.00
0
Vacuum B*r Bkflow(1-4)
$0.00
0
Receptors
$0.00
0
Vacuum Brkr Bkflow(5+)
$0.00
0
Septic Tank
$0.00
0
Wash Basin
$9.80
1
Sewer Cap for Demo
•$0.00
0
Wash Basin Set
$19.60
2
Sewer Connect
$24.65
1
Waste and Vent System
$0.00
0
Sewer Private Line
$0.00
0
Water Closet (Toilet)
$29.40
3
Shower
$9.80
1
Water Heater / vent
$12.30
1
Sink, bar
$0.00
0
Water Piping (Inst or Rep.)
$0.00
0
Sink, commercial
$0.00
0
Water Re -pipe
$0.00
0
Sink, Floor
$0.00
0
Water Service
$9.80
1
Sink, kitchen
$9.80
1
Water Softener
$0.00
0
Sink, service/mop
$9.80
1
OTHER
$0.00
Spa (private)
$0.00
0
VIOLATION
$0.00
Spa (public)
$0.00
0
PLAN CHECK
$0.00
REINSPECTION
$0.00
0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access r9�946F191cFiHbA @PcFFF"9%1aW§.AAcl related
EXPIRATION: This permit shall automatically ex in 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 expirationof this permit.
FOR INSPECTIONS CALL: (714) 754-5626
2446-46 (6100)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance 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, 1 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 37M OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby affirn 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. N Class N
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirn 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 affirn that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ 1, as owner of the property, or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose 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.).
❑ 1 am exempt s Business and Professions Code for this reason:
Signature: Date: Z- Z Z--
Owner ID verified by drivers license. ❑ Yes U No Drivers License No. Expires:
Verification of Ownership by (type of document, Le. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
......................................................................................................................................................................................................................................................................................................................................
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 a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? IJ Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
............................................................................................................................................................................................................................................................................................................................................................................................
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
.......................................................................................................................................................................................................................................................................................................................................................-...................................
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 .been made? ❑ Yes ❑ No
.........
....................................................................................-............................................................................................................................................................................................................................................................................................
e (It'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. 1 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.
Sig ure Leg O er( 2D�a=a
And/Or Authorized Applicant 1 Date O
CODE #. INSPECTION TYPE DATE INTITIAL�4 CODE INSPECTION TYPE 2&U IN$lAL¢
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 200 Final Plumbing �� •9 ' d 171V
200 Final Re-Roof 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