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Home My WebLink About239 ALBERT PL - Building Permits� �" 3890W • COSTA MESA BUILDING-SAFETY DEPAF P.O. BOX 1200 COSTA MESA, CALIFORNIP For Applicant to Fill in Completely BUI4DING AOORESS � OWNER /.,;�� : o � � Z . d U CITV ZQ CANSTRUCTION O � LENpER am J � BRANCH J N Q W ADORESS p] J J m ARCHITECT a OF ENGINEER UQ W � AODFESS aW W Z CONTRACTOR J Q m Z J � ADDPESS W w ZF CITV w O STATE LIC. NO.� � � SIZE OF LOT r� TEL. NO. CITV 2 _ LIQ Nr Q�lrf INO. OF BLDGS. NOW ON LOT A.P. NO. ' BUILDING ADDRESS R E Ptiiu # �,r��c9.50 iUG 23-74�M�,001659 TION FOR BUILDING PERMIT DATE RECEIVED D TE ISSUED -�Z3-33 R"'T � 3� LOT� BLOCK \ ( � /J LUE O C $ / TVPE ROUP � r DATEJ%��J NO.OF USE OP N PIANS Z BUILOING VARDSAPPqOVED VARD: MAIN BUILDING ACCESS EXI5TINGBIOG. �,(�/�/' . � F FT. H SIZE OF 4� /� NO. OF p� ..r Z NEWBLDG.�C {1 FOOMS STORIES L.SIDE �V FT.— FT. a EXTERIOR WALL ROOF L, �% COVERING COVERING REAH r�FT. FS. J USE OF BUILDING AND WORK TO BE PEFFORMED DI5TANCE BET. BET. MAIN & d MAIN BLDGS. ACC6S, BLDGS. a a 4 � C URP. #`- A,VPROVED 0 y � . / ROVED G.l ��3 �J w / Z � Q UI here6y acknowlatl8a thet I heve reatl this apPlication antl staie � ihet tha ebove intormetio� is correct antl agree to comply with � all laws reBulatinB builtlin8 conctrucNon, antl I shall not employ � any person in vtolation of the workmen's compensatian laws ot the State ot California. m ZI hereby cartify that I am prooerly licansetl as a concracmr untler SQ. FT. o the Stata of Californie Business antl Protessionc Code, Dl�ision 3, THE AMOUNT SHOWN UNDER VALUATION IS FOq C�epter 9, and that such licenus are in full force end affect, or I THE PURPOSE OF ESTABLISHING A PERMR FEE ONLV: Q am exempt trom the provisions of the State of California Business VALVATION � B!(/ antl Professions Cotl , ivision 3, Cha tar 9. pEqM1T FEE $ � � Signature of � � � G�j�ll m Permlttae $ �� d� p�,qN CMECK $ E b,V o / LL Authorized Agent TOTAL FEE $ � �� '. � a2� COSTA MESA BUILDING-SAFETY DEPARTMENT P. O. BOX 917 GOBTA MEBA. CALIFORNIA For Applicanf to Fill In Compleiely � TYPE OR�PRINT ADDRH6� /��J�� .V� COSTA MESA. CALIFORNIA n�%�1 �" _ l_"_.. �� 'T _ ■ MAIL FE RECEIVED ; JUn 2 a is63 FINANCE. DEPT. , APPLICATIO�FORO�E&�{A MESA BUILDING For Office Use Only • wECEIPi NO. t�¢BMIT NO. � RECEI BY ��<l• • ,c. �', a BUILDING � MESA. CAi1FORNIA AODRESS SQ /77l�- ZONING � -�_� ZO NO.OF U6E OF NEW 'f+ �d�..%�iy CITY �� I I PLANB Z BUIL�INO W 1 STATE '� TEL. �eow� �y Le t 313 /"/� !��r�� •i� LIC. NO. N�• DEBCRIPTION SIZE S� / � I No. ov etoca. O � ,Q � Z 3— O�— OF LOT O �(p S"� HOW oN Loi p, p, NO. � v USE OP EXIBfING BLDG. -��- APPROVED ALLOWED 56TBACK LINB PROM ` / q / <C6P�TCR 4N8 BT.1 cEtmR OP BTNCET d� REAR YARD J FRONT SS FT. � l_ IN. SIDE YARO I LEYT �0' I RIGNT S!� ' R. SIDE � FT. -� IN. - DESCRIPTION OF WORK � L. SIDE FT. IN. NEW I II ALTERATION I II ADOITION I REAR / 8 t Fi. IN. REPAIR I II MOVING I II DEMOLISH I BVPROVE� �,1� DATE "' /Z 7 `� S¢E DING oc '3 ��ROOMS � STORIES � HOLD FOR`S ECIAL RLQUIRFMENTS EX78RIOR WALL ROOF I,, (/ / COVERING .S��C'� I COVERING W ..Jn�/t �S ��e I�e�erre ,i��/e �oy USE OF BUILDING AND WOfiK TO BE PERFORMED n y - -S�.0 lq� (n ec 4 /J'P...q��C (/ is� �G �m;� .��e�%r • _ /3�3_3 -, . •�- - dd"� � HEREBY ACKNOWLEDGE TXAT � HAVE RE�D TXIB MPLIGTiON THE AMOUNT BHOWN UNOER V�LUATION 18 FOR TH¢ ANp STATE TXAT THE ABOV6 I6 COPRECT ANO A6REE TO COM- pURP08¢ OF ¢BTABLIBHING A vERMIT FEE ONLY. PLY WITX AI.L QTY ORDINANGfi6 ANO BTAT¢ LAW9 R80UI.ATING 6UILDINO CONBTRURION. � � VALIIATION / PERMnI7TEE �%�Th�GrT '' meS IV PERMIT FEE ��/ Y o `'�J '///,�'/��/y/�/ $ �� O^ PLAN CHECK $ �� /S� A� ORIZED AGENi�/!�"' "/ �" 76i�/ � 0 TOTAL FEE a conditions of Subdivision No. 423: 1. Dedication to the City of Costa Mesa of all land 30' from the �� center line of existing Albert P1ace for street purposes. 2. 7nstallation of residential sidewalks across the fronta�e of parcels A, B, and C of the Subdivision by the applicant at his eicpense, under the direction of the City Enginaer� and also concrete driveway approaches. a. No Building Permits wil.l be issued until satisfactory arrange�ents have been made with the City of Costa Mesa by either depositing a Cashier's Check, a l�rsonal Undertaking Bond, or a I�tter of Credit with the City for the required side- . walks and concrete driveway approaches. a . • �� a .•w � �-io-62 ✓ RT7TT.TlTNf1 PF.RMiT N(1 GENERAL CONTRACTOR p�mep-$1dT� VALUE $ 15�330.00 AP No. 11H-123-OS LOT TRACT PIRE ZONE D�SCRIPTION OF WORK Sing. F2in.Res. CNSPECTIONS I Signatute -DATE GROUP I&J TypE �7,pNg -1 W a, •�T2,T �, � SUBCONTRACTOA T ,r�RMI'I'STISSUED coat OCCUPANCY �I .� .•fl� Y ,�: J� `r ��v �;�� I CQSTA MESA BUILDING-SAFETY DEPARTMENT .• F.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink Only ADIDRESS �1� tip�f/PT� /'�. OWNER OR � TENANT �, MAI LI NG �ry ADDRE55��7/ � � �� y TEL. CITY/ �—.,� �^ //'/t�7A Nq..{{(Q /(/ CANSTRUCTION LENDER BRANCH ADORESS CONTRACTOR ADDRESS � ,�. 4/04/�19 APPLICAT[ON I RECEIVEDBV � A.P.NO. �IQ i UNIT OR SPACE NO. TR.NO. LOT NEW ADD ALTER REPAIR OWNER USE / VALUE E DATE BLK. TEI. CITV � Q� NO y F STATE CITV �� APPROVEDSET ACKS 11Q NO. LIC. NO. � 512E NO.OFBLOGS. (FROM LST E L OF lOT NOW ON LOT RO F. a USE OF .G � EXISTING BLDG. h � Separate permits are required for L DE Fr. � electric, plumbing and heating work. REAR Fr. FUSE OF BUILDING AND WORK TO BE PERFOflMED PLqNNING ACTION a q DATE a iCp� /O " L,FC• APPROVED 7 / qppq . r- - a a w � I hereby aeknowletlga that I hava reatl this application and state � y� that the ebova information is cortect and agtee to comply with �+ all laws regulaiing builtling construction, entl I shall not amploy ,� any parson in violation of Me wo�kman's compensation laws of ° � the Staie ot Californla. ..; SQ. FT. � m 3 I hareby cartify that I am properly licensetl as a contractor untler °' the State of California Business and Professions Code, Divlsion 3, THE AMOUNT SMOWN UNDER VALUATION IS FOR m Chapter 9, and that such licanses ara in full force and effect, or I THE 7URPOSE OF ESTABLISHING A PERMIT FEE ONLV: � am exempt from the visions of the State of Calitornia Business a VALUATION PERMIT FEE $ /Y». N antl Protessions Co ivision 3, Chapter 9. ..�C/ / m Penatur�e�of �/ �_ / "� $ �� S TAX CHECK $ � � .�G.✓r (/�i . Authorizetl Ageni Oate ��J! � TOTAI PAI D $�. �� U TL� ' CK � f - OWNER M�, JOB ADDRE55 GENERAL C01 AP�.u�p.118-L' -x- „v.w IIU.;^_:-.4��TIONS sG"s;::. WS W�TER AOUGN PLUMBIN( DATE I��l� 1:7_T�1 �iL'1�4�]J i•lil�llq ROUGH MEATING ANO AIR CONOITIONING TEMPOR�RV SERVICE OR POLE - UNOERGROUNO � POWER � ROUGH WIRING TRENCNES FOAMS STEEL RE FLOOR SYSTEM BONO BEAM � STEEL REINFORCE [ SHEFTHING FRAME RNO FLRSNING � LRTHING — IN r] OUT ❑ PLRSTER.BROWN COPT ST' �URqL,F H �. VENT. REFRIG. �NO �.C., FINAL ANO GAS TEST (-I SUBCONTRACTOR NG PERMIT N0. 47777 CITY OF COSTA MESA o F B!/ILDING DIYISION i � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us �.�4b�Q� FOR INSPECTIONS CALL: (714) 754-5626 � / PERMIT NUMBER: E09-00250V PERMIT TYPE ELEC APN: 42607313 JOB ADDRESS: 239 ALBERT PL CM Vicinity: KITCHEN - � STATUS: ISSUED DATE ISSUED: 09/28/2009 ISSUED BY: BJK Suite/Unit: SCOPE OF WORK: KITCHEN REMODEL TO INCLUDE NEW SINK AND RELOCATION OF 3 SWITCHES. NO OTHER WORK AUTHORIZED WITH THIS PERMIT. OWNER: �MC COY, RYUKO PHONE: APPLICANT: VAZIRIAN, REZA PHONE: 949-472-8453 CONTRACTOR: VAZIRIAN ENTERPRISES Address: 23582 MOUL70N PKWYUnit: SUITE 110 Ciry/State: IAGUNA HILLS, CA ZipCode: 92653 ELECTRICAL PERMIT FEES Electrical Plan Check Fee: $0.00 Electrical Permit Fee: $26.80 Reinspection Fee $0.00 TOTAL FEES $26.80 Address: 239 ALBERT PL Unit: City/State/Zip: COSTA MESA, CA Address: 23582 MOULTON PKWY Unit:SUITE 110 City/State/zZip: LAGUNA HILLS, CA � License No. 881166 PHONE: 949-472$453 CELL: NOTICE: The wofk 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 EXPfRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authonzed under this permit to be considered legal, such work must wmply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and fnal approval will result in the expiration of this permit. CODEN. INSPECTIONTYPE �ATE IN1111RL5 COOEp INSPECTONTYPE OAT� INTITIALS 1616 Fized System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing �� 200 Pinal Re-Roof 210 Final Electnwl 201 Pinal BIacWRetaining Wall p12 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Si9n 222 Final Si�e 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalry of perjury one o( Ihe following declaretions: ❑ I have and will maintain a certifw[e of consent to self-Insure (or workers' compensa[ion, as provided for by section 3700 0( Ihe Labor Code, for Ihe ?� perto mance of �he work for which this permit is issued. have antl will maintain workers' compensation insurance, as requiretl by section 3700 of the Labor Code, (or the perfortnance of the work foi which ihis pertnit is issued. My workers' compensation Insurance carrier and policy number are: � � �� ^ /�, 'Carriei: ' V (Thissetlqnnee nofbecomple(etldfbep�p�onehundretlCollars(8100)oilessJ Policy Number: =� / ��%�-( «� ❑ I certify Ihat in the performance of the work for which �his permit is issued, I shall nol employ any person in any manner so as to become subject to the workers' compensatio laws of Califomia, and agree that it 1 should 6ecome subject to th,.w0� fc'¢� compensa[ion provisions o( Section 3700 of lhe Labor Code, I sl II f� orthwit comply with these provisions. ,q � � — _' i/a�ti Ap re Date r WARNING: ILUR SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALI SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrtn Ihat I am licensed under provisions of Chapter 9(commencing with Section 7000) of Division 3 of ihe Business antl Professions Code, and my license is in full force and effect. fj� Lic: # Class # : � �/ d q � � � 1 r7 / f C nlr � s Si a Date CONSTRUCTION LENDING AGENCY: ❑ I hereby aKrm [hat there is a consiruction lending agency for Ihe peAormance o( the work for wfiich this pertni[ is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: SignaWre OWNER-BUILDER DECLARATIONS: I hereby aKrm that under penalry 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 conshuc[, alter, impmve, tlemolish, or repair any stmcture, prior to its issuance, also requires lhe applicant for such pertnit b file a signed statement that he or she is licensetl pursuaN lo lhe 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 Iherefrom antl the basis tor the allegetl exemption. Any violalion ot Section 7031.5 by any applicant for a permit subjects ihe applicant to a civil penalty of not more than five huntlretl tlollar5 ($500).�: ❑ I, as owner of lhe property, or my employees with wdges as Iheir sole compensation, WILL DO THE WORK, antl the struc[ure is no[ intended or oflered (or 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 thmugh his or her own employees, provided that such improvements are not intended or oKeretl for sale. If, however, the building or improvement is sold within one yeai of completion, the owner-builder will have the burden oi proving that he or she did nol build or improve for purpose of sale.). ❑ I, as owner o( the pmperty, am EXCLUSNELY CONTRACTING WITH LICENSED CONTRACTORS to cons[mct the prqect (Sec. 7044, Business and Professions Code: The contractors License Law dces not apply to an owner of property who builds or improves thereon, and vfio contracts for such project with a contractor(s) license pursuant to the Contractas License Laws.). `❑ 1 am exempt under sec.. Business and Professions Code for ihis reason: Owner ID verified by driver s �icense. ❑ Yes ❑ No Driver's License No. Expires: Verifcation of Ownership 6y pype of document, i.e. - property tax bill or deetl): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify ihat no excavation fve (5) or more feet in depth in�o which a person is requiretl ro descen4 vrill be made in connecl'an with vrork authorizetl by this pertnit, and Iha� no building sWcture, sca(folding, talsework, a demoli[ion or dismantling thereof, will be more than thirty-six (36) fee[ high. (Chap. 3.2, Gry 2, Art 2, Sec. 341, Ttle 8, Califomia Administ2tive Code). ❑ As owner-builtler, I will not employ anyone to tlo work which vrould require a permit fmm the Division o( Industrial Safety, as no[ed above, unless such person has a permit to do such work from the division. ApphwnYs SignaWre Dale Division of Industrial Sa(ety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will Ihe applicant or present or future building occupant need to fle antl certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Seclion 25505 of the Califomia Health and Safety Cotle requires, with some exceptions, tha[ a Business Plan be (led with Ihe Costa Mesa Fire Deparlment by every business which has at any one time during a reported year a quantiry of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic tee[ of compressed qas at standard tempereture and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazartlous matenals? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department hy eaCh bu5ine55 whiCh al any one lime ha5 on hand a quanlity of aCutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o( 55 gallons, or 200 cubic feet o! compressed qas at standard temperature and pressure). 3. Does or will Ihe applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Seclion 25534 of lhe Califomia Health and Safety Code provides lhat the Costa Mesa Fire Department may require the preparetion, certifca[ion and fling with the Fire Deparlmen[ of an RMPP by businesses which are required lo register acutey hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 0( the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will Ihe applicant or present or tuNre building occupaM require for Ihe vrork which is Ihe subjec[ of this application a permit (or such consVuclion or modifcation fmm the South Coast Air �ualiry Management Dishict or from any other air pollution con[rol distric[ or agency? ❑ Yes ❑ No (Sectbn 65850.2 of the Califomia GovemmeN Code requires that the requestetl information be fumishetl on applications fa non-residential building permits�. 6. Will any pan of the facility to be constNctetl under [his permit be within 1000 (eet from the outer boundaries of a school? ❑ Ves ❑ No Q('yes", [he facility must meet the requirement of Sections 25534 and 42303 of ine Cali�omia Health and Safety Code). 7. If a permit (rom [he South Coasl Air Quality Management District or other air pollution control tlisVict or agency is required (or the vrork which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. Qf'yes", attach certifcate of compliance from the appropriate air polNtion control oKcer). CERTIFICATE OF COMPLIANCE: I certify that under penalry of perjury Ihe information given above is correcl. I agree to comply with all slate laws and city ordinances regartling Hazardous Materials and Emissions. SignaWre �ale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read ihis application and s[ate that the intormation given is correcl I agree to comply with all state laws and city ordinances relating uilding construction, and authorize representatives ot the City of Co Mes to enter upon ihe above-described property for inspection pur ses. I ag e nol to occupy or allow occupancy o( any building aulhorized b this permit til fnal inspection. agnawreoi e ai�r�s) Date n SignaWre Oate (D �y 905]J6(107) � An�/ ze0 Appli�anl,� Dale �� CITY OF COSTA MESA . o "'F BlIILDING DIVISION r . � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us �. POR INSPECTIONS CALL: (714) 754-5626 ��'°""°� PERMIT NUMBER: P09-00127 PERMIT TYPE PLUM APN: 42607313 JOB ADDRESS: 239 ALBERT PL CM Vicinity: KITCHEN STATUS: DATEISSUED: ISSUED BY: Suite/Unit: ISSUED 09/2812009 BJK SCOPE OF WORK: KITCHEN REMODEL TO INCLUDE NEW KITCHEN SINK AND RELOCATION OF 3 SWITCHES. NO OTHER WORK AUTHORIZED WITH THIS PERMIT. OWNER: PHONE: APPLICANT: PHONE: MC COY, RYUKO VAZIRIAN,REZA 949-072•8453 � Address: 239 ALBERT PL City/State/Zip; COSTA MESA, CA Address: 23582 MOULTON PKWY :SUITE 110 City/State/zZip: LAGUNA HILLS, CA CONTRACTOR: VAZIRIAN ENTERPRISES License No. 881166 Address: 23582 MOULTON PKWY SUITE 110 PHONE: 949472-8453 City/State: LAGUNA HILLS, CA ZipCode: 92653 CELL: ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: PLUMBING PERMIT FEE SUMMARY PLAN CHECK FEE: PERMIT FEE: TOTAL FEES: $0.00 $33.30 $33.30 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia 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 permit. CODEO. INSPECTIONTYPE DpTE ixnna� CODEI INSPECTIONTYPE ORTE INTITIAt i616 Fized System Final Fire Preveniion 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 Final5i9n 222 Final Site 204 Final Demolition 250 Final BuildinglOcCupancy WORKERS' COMPENSATION DECLARATION: I hereby aKrm under penalty of perjury one of Ihe following declaralions: ❑ I have and will maintain a certifcate o( consent to self-Insure fot worke�s' compensation, as provided tor by section 3700 of the Labor Code, for the peA mance o( the vrork for which Ihis permit is issued. I have antl will maintain workers' compensation insurance, as requiretl by section 3700 0( the Labor Cotle, for the perfortnance of the vrork for which this pertnit is issued. My workers' compensalion Insurance carrier and policy '�Cam eer are: � ��G� /"'� N� � � (Th�ssM.onneednorbe)cnm/dyetMtltheperm(rt�is�valquetlatonehu�iMdollars(St00)wlessJ Policy Number: / `�/ � J � V/ ❑ I certify that in the peAormance of the vrork for which this permit is issued, I 5hall not e ny person in any manner so as to become subject to Ihe workers' ompensat n laws of Califomia, and agree Ihat if I should become sub� ct [o the wo ers' compensation provisions of Section 3700 of . the Labor ode, I II f liwith comply with these provisions. - 2 �fli sSignaWre ° Dale• ' WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOl1SAND DOLLARS ($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 untler provisions of Chapter 9(commencing with Sec�ion 7000) of Division 3 of Ihe Business and Professions Code, and my license is in�ull (orce nd eRec[. Lic. # ___� Class # ' � ��,a�— �Z�� Contratlor'sSgnaWre Date > CONSTRUCTION LENDING AGENCY: ❑ I hereby aKrtn lhat Ihere is a consWction lending agency for the pedortnance of the work fa which this permit is issuetl. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: 9gnaWre Dale OW NER•BUILDER DECLARATIONS: I hereby affrm that under penalry ot perjury that I am EXEMPT FROM THE CON7RAC70RS LICENSE LAW for the following reason (Sec. 703L5, Business and Professions Code: Any city or county which requires a permit to construcl, alter, impmve, tlemolish, or repair any sWcture, prior to its issuance, also requires the applicant for such permit to Lle a signetl 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 ihe Business and Professions Code) or that he or she is exempl Iherefrom and [he basis for the alleged exemption. Any viola[ion of Section 7031.5 by any applican[ for a permit subjects �he applicant [o a civil penalty of not more than fve hundretl dollars ($500).): ❑ I, as ovmer of the property, or my employees wilh wages as their sole compen5a[ion, 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 ovmer 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, ihe 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 WI7H LICENSED CONTRACTORS [o construct the project (Sec. 7044, Business and Pro�essbns Code: 7he contractors License Law dces not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contracta(s) license pursuant to the Contractors License Lavrs.). ❑ I am exempt under sec. Business and Professions Code for this reason: SignaWre 309A6(3/0]) Owner ID verifed by drivers iicense. ❑ Yes ❑ No Driver's License No. Expires: Verifica�ion of Ownership by (type of document, i.e. - property lax bill or deed): DIVISION OF INDUSTRIAL SAFEN PERMIT CERTIFICATION: ❑ I hereby certify tha[ no excavation frve (5) or more (eet in depth into which a person is requiretl to descend, will be matle in connectbn vrith work authorized by this pertnit, and that no building sWcture, scaffdding, falsework, or demolition or dismantling Ihereof, will be more �han thirty-sia (36) fee� high. (Chap. 32, Grp 2, Arl 2, Sec. 341, Title 8, Cali(omia Atlministrative Code). ❑ As owner-builder, I will not employ anyone to tlo work which vrould require a permi[ from the Division of Indus[rial Sa(ety, as noted above, unless such person has a permit to tlo such vrork fmm [he division. Applicanl's SignaWre Date Division of Induslrial Safety Permit Number HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 7. Will the applicant or present or fWure building occupant need to file and certify a Business Plan for emergency response ro release or threatened release of a hazardous material? ❑ Yes ❑ No (Seclion 25505 of the Califomia Health and Safety Code requires, with some exceptions, tha[ a Business Plan be filed with lhe Costa Mesa Fire Department by every business which has at any one time tluring a reported year a quantity of hazartlous materials equal to or greater than a weight of 500 pounds, or a volume o� 55 gallons, or 200 cubic /eet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or fuWre building occupant need to fle a regisUation form for aculely hazartlous materials? ❑ Yes ❑ No (Sec[ion 25533 of the California Health and Sa(ety Code, with some eaceptions, requires registra[ion with the Cos[a Mesa Fire Departmenl by each business which at any one time has on hand a quantity of acutely hazartlous materials equal to or greater [han a weight of 500 pounds, or a volume o( 55 gallons, or 200 cubic feet of campressed gas at standard �empereture and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Managemen[ antl Prevention Program for awtely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Cos�a Mesa Fire Department may require Ihe preparation, certification and filing with the Fire DepartmeM of an RMPP by businesses which are required ro register acutely hazardous mateiials 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 application a permit for such constmction or modification from the SouM Coasi Air Qualiry ManagemeM Dislrict or (rom any other air polWtion contml dis�rict or agency? ❑ Yes ❑ No (Section 658502 of the Califomia Govemment Code requires Ihat the requested in(ormation be fumished on applications fa nornresitlen[ial building pertnits). 6. Will any part of the (acility to be cons[ructed under Ihis permit be within 1000 feet from the outer boundaries o( a school? ❑ Yes ❑ No Qf "yes", the faciliry must meet the requirement of Sections 25534 and 42303 of the California Health and Safery Code). 7. If a permit from [he South Coast Air Quality Managemenl Districl or other air pollution control district or agency is requiretl for the vrork which is the subject of this application, have all of the tlisclosures prescribed by Catifornia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No &(I( "yes", attach certifcate of compliance from the appmpriate air pollution control oKcer). CERTIFICATE OF COMPLIANCE: I certify that under penalry of perjury the information given above is correcL I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certi(y under penalty o( perjury that I have read this application and state that Ihe information given is correct I agree to comply with all state laws and city ordinances relating ro building cons[ruction, and authorize representalives o( the City of Cost to enter upon Ihe above-described property (or inspection pyr ses. I agr e not to occupy or allow occupancy of any building au�horized y Ihis permit u[il fnal inspection. Signal ol L i Owneqs) �a�e � � Antl/or Aul onzeE App4wm aie �