HomeMy WebLinkAbout107 ASPEN LN - Building Permitst
9
0460 1
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For A icant FID in Completely — Use Ink Only
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ATION FOR STRUCTURAL PERMIT
RECEIVED BY Iy6iF]ECIVED p/ E ISSUED/
OWNER a V 4 W
— —
MAIL BUILDING )
A D OR ESPQ Dove St . #225 ADDRESS/&4Z ew �/, ' N G�
TEL. TMJ LJT BLOCK
CITU TTpWn(1P1c RF!a.r•.h No.752-507
BRANCH
OWNV
ADDRESS
W(� _ i,e� �E ,S�
s (-3-�-� U$ /
ARCHITECT 0145-585
OR ENGINEER Brion Jeannette SSOC.
FIRE
ZONE TYPE GROU
04 N N wpSfit Blvd #202
ADDRES
�'D
APPROV f�
CONTRACTOR
By DATE D
ADDRESS
TEL.
ZONE
NO. OF
USE OF NEW/ ,
CITY NO.
PLANS �7
BUILDING W
STATE CITY
YARDS APPROVED
YARDS APPROVED
LIC. NO. LIC. NO.
MAIN BUILDING
ACCESSORY BUILDING
SIZE
NO. OF BLDGS.
(FROM C/LS BEET)
OF LOT
NOW ON LOT
FRONT FT.
FT.
USE OF
EXISTING BLDG.
El. EIDET.
FT.
Separate permits are required for
L. SIDE FT.
FT.
9
electric, plumbing and heating work.
REAR FT.
FT.
USE OF BUILDING AND WORK TO BE PERFORMED
DISTANCE BET.
BET. MAIN &
MAIN BLDGS.
ACCESS. BLOCS.
at)C
URP. %�L�c
DATE
APPROVED ' � i -7
!O
APFlyPROVE 1. -
DATE /Q •2%— !
HOLD FOR SPECIAL
ZEOUIRFMFNTs
I hereby acknowledge that I have read this application and state
that the above information is correct and agree to comply with
all laws regulating building construction, and I shall not employ
any person in violation of the workmen's compensation laws of
o
Z
the State of California.
I hereby certify that m properly licensed as a contractor under
SQ. FT.
n�
THE AMOUNT SHOWN UNDER VALUATION IS FOR
the State of Galifor. usiness and Professions Code, Division 3,
m
Chapter 9, and licenses are In full force and effect, or I
THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
em exempt fr ovisions of the Slate of California Business
e
and Professio v' 3, Chapt
VALUATION
PERMIT FEE $
n \
M
AN CHECK § 0 t��
G
Signature of
Permittee
^)
$ 5/ /
/
IL
TAX $
Authorized Agent
-U
TOTAL PAID $
Y
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
Job Address:
107 ASPEN LN
Suite No
Vicinity:
Parcel Nunmber:
43917214
Applicant:
SCOTT LITTLEFIELD
Address:
24707 SAN FERNANDO RD
SANTA CLARITA, CA
Owner:
KLIMOW, KATHERINE D
Address
107 ASPEN LN
QTY
COSTA MESA, CA
Contractor:
Address:
Arch / Eng :
Address:
PLUMBING PERMIT
Phone: (661)259-7131
Zip: 91321
Phone:
Zip: 92627-1360
AFFORDABLE WATER HEATERS & PLUMBING
24707 SAN FERNANDO RD
SANTA CLARITA, CA
CHANGE OUT WATER HEATER.
Phone: (661)259-7131
Zip: 91321
License: 627368
Phone:
- -Zip:
License:
SCOPE OF PERMIT
77 FAIR DRIVE, GUS I A MESA, GA 92626
Status: ISSUED
Applied: 12/27/2004
Issued: 04
ISSUED BY:
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 .
260646 (6/00)
FEE SUMMARY,.., -
AMT
QTY
-
AMT
QTY
-
AMT
QTY
ISSUE FEE
$23.50
-
Laundry Tub / Washer
$0.00
0 -
Sump Pump
$0.00
0
Backflow irrigation
$0.00
0
Landscape Irrigation
$0.00
0
Swimming Pool
$0.00
0
Backflow Preventer
$0.00
0
P -Trap
$0.00
0
Trap Primer
$0.00
0
Bathtub
$0.00
0
Pressure Regulator
$0.00
0
Urinal
$0.00
0
Clarifier System
$0.00
0
Process Piping (per 10 ft)
$0.00
0
Vacuum Brkr Bkflow(1-4)
$0.00
0
Connect (Ice,Soda,etc)
$0.00
0
Receptors
$0.00
0
Vacuum Brkr-Bkflow(5+)
$0.00
0
Dental Units
$0.00
0
Septic Tank
$0.00
0
Wash Basin
$0.00
0
Dishwasher
$0.00
0
Sewer Cap for Demo
$0.00
0
Wash Basin Set
$0.00
0
Drain, Floor
$0.00
0
Sewer Connect
$0.00
0
Waste and Vent System
$0.00
0
Drain, Rainwater
$0.00
0
Sewer Private Line
$0.00
.0
- ', Water Closet (Toilet)
$0.00
0
Drain, Roof
$0.00
0 -
Shower
$0.00
0
- Water Heater / vent
$12.30
1
Drinking Fountain
$0.00
0
Sink, bar
$0.00
0
Water Piping (Inst or Rep.)
$0.00
0
Expansion Tank
$0.00
0
Sink; commercial
'$0.00
0
Water Re -pipe
$0.00
0
Gas Earthquake Valve
$0.00
0
Sink, Floor
$0.00
0
Water Service
$0.00
0
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 .
260646 (6/00)
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 woars' compens Ion Insyrance carder and policy number are:
Carrier: Tacom_p � Policy Number:
(This section need not be completed i/ 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 Calffogne, 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 pro" slon .
Applicant Signature: I' Date: j Z 7' 0
WARNING: FAILURE TO SECUR ORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE 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. Lia # d"i M bClass q C It
Contractor's Signature: iffir
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).):
❑ 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.).
❑ 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 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
Permit to do such work from the division.
Signature: Dale:
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 excep(ions, 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 theappplicant or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes 11 ;To
(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.
...................... ....................... ......................................................................... ............................ ..................................................... ................................................................. ........................................................................ .... ......... I..............................
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,,ppermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes a 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 ❑ Na
(If'Ws", the facility must meet the requirement of Sections 25534 and 42303 01 the California Health and Safety Code).
............................................................................................................................................................................................................................................................................................................................................................................................
7 If apermit 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 AUTHORIZAT1ON 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.
Signature f Legal ner(s) Date
1'L- 2-7-O4
And/Or uthorized Applicant Data
CODE P, INSPECTIONTYPE glyjf, INiII1A6$ CODE! INSPECTION TYPE PAI[ INTMUS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing RIC-
�-0
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
�Y
CITY OF COSTA MESA
BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT P IT NUMBER
PERMIT nn-nnclnst
(714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address:
107 ASPEN LN
Plan Check:
$0.00 Calc Valuation: $3,400.00
Status: ISSUED
Suite:
SMIP Res:
$0.50
SMIP Com:
Applied: 06/21/2000
Vicinity:
UNITS 107 & 109
Inspection:
$0.00
Issued: 06/21/2000
Parcel Number:
43917214
Zoning:
Applicant:
COOTER, LYLE
ISSUED BY:
Address:
23015 DEL LAGO
Phone:
(714) 583-1858
LAGUNA HILLS, CA
Zip:
92653
Owner:
LAUREL POINTE HOA
Address
107 ASPEN LANE
Phone:
COSTA MESA, CA
Zip:
92627
Contractor: PRO -TECH WEATHERPROOFING
Address: 23015 DEL LAGO
Phone: (714)583-1858
LAGUNA HILLS, CA
Zip: 92653 License: 620476
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF EXISTING 2 UNIT CONDOMINIUM FOR "LAUREL POINTE HOA" (24 SO). TEAR OFF EXISTING SHAKES,
INSTALL 1 LAYER OF 15# FELT UNDERLAYMENT, & REROOF WITH 30 YEAR "GAF" COMP SHINGLES,
2 UNIT CONDO INCLUDES UNITS 107 & 109 ASPEN LN.
Total: $97.75
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 Proposed: o
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 hays, 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
FEE SUMMARY
Plan Check:
$0.00 Calc Valuation: $3,400.00
Permit:
$97.25 Claim Valuation: $3,400.00
SMIP Res:
$0.50
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total: $97.75
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 Proposed: o
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 hays, 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
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 antl 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: ✓ � L' L�- p✓ vj%— FPolicyNumber.. wc, -3 �y�>�
(This section need not be completed if the pemtlt is valued st one hundred dollars ($100) or less.)
❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers'
compensation laws of California, and agree t t If l should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: ,--Date: �.7 z/ J
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($too,ODD), 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 affirn that I am licensed /Iunder provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
farce and effect. Lic. k h Z.o 4-1 class It GTI 4
Contractors Signature: Date: Of.a o
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 -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
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 contractors)
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 drivers license. ❑ Yes ❑ No Driver's 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 thlrty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, Califomia 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).
__. _ Ing Occupant
.__-_.--_... ____—... ..-.—_.-_...-._.........._-
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materiels? ❑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 o1 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 I 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 aPpermit 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 gi]1he
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 upo
above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of Legal Own�r(s) to
D `o
And/Of Afilhortzed Applicant Date
CODE r. INSPECTION TYPE 2A3 1111IL9L¢ CODE[ INSPECTION TYPE L1ATf, INTRIALS
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 rectory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
2446-46