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` CITY OF COSTA MESA '
BIII�.DINiG DIVISION
77 FAIR DRNE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www costamesaca.qov
FOR INSPECTIONS CAL�: (714) 754-5626
PERMIT TYPE MECH
APN: 14157211
JOB ADDRESS: 2873 BALLOW LN CM
Vicinity: HALLWAY CLOSET
SQ. FT: 0
PERMIT NUMBER: M12-00024
STATUS: ISSUED
DATE ISSUED: 02I1012012
ISSUED BY: RMD
Suite/Unit:
SCOPE OF WORK: MECHANICAL PERMIT TO REPLACE FAU < 100 K BTU LOCATED IN HALLWAY CLOSET FOR SFD.
COMPLIANCE FORMS ATTACHED TO CITY PERMITAND JOB CARD.
OWNER:
PHONE:
APPLICANT:
PHONE:
MORELAND, PATRICK GERARD
TIERNEY, PATRICK
714-642-0124
CONTRACTOR: SUNSET MECHANICAL �
Address: 27331 YARMOUTH LANEUnit:
City/State: HUNTINGTON BEACH, CA
CELL:
MECHANICAL PERMIT FEE SUMMARY
MECH ITEM FEE: $38.30
PLAN CHECK FEE: $0.00
INVESTIGATION FEE: $0.00
REINSPECTION FEE: $0.00
TOTAL FEES: $38.30
Address: JR Unit:COSTA MESA, CA
City/State2ip: 2873 BALLOW LN
Address: Unit:
City/State/zZip:
License No. 604858
PHONE: 714•642-0124
ZipCode: 92646
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
GOpE t, INSPELTIONTVPE ATE INTIPALS $�ODE( INSPEC710NTYPE DATE �IN7q111RL5
1616 Fixed System Final Fire Prevention 206 Final Mechanical x a— �y—��y��
1266 Pool Spa Final 208 Final Plumbinq
200 Final Re-Roof 210 Final Elecincal
201 Final BIocWRetaining 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 Bwltling/Occupancy
�
WORKERS' COMPENSATION DECLARATION:
I hereby aKrm untler penalty of perjury one of ihe following declarations:
❑ I have and will maintain a cenificate of conseM [o self-Insure for workers'
compensation, as provided for by section 3700 of the LaSor Code, (or the
peAormance of ihe vrork for which lhis permi� is issuetl.
❑ I have antl will maintain wnrkers' compensation insurance, as requiretl by
section 3700 of the Labor Code, for the peAortnance of the wnrk for which this
pertni� is issued. My workers' compensation Insurance carrier and policy
number are:
Carrier
(This secl.on need nof be comple(etl AMe permR is valued af one �undredCdlars (3100J a less )
Policy Number:
� I certify tha[ in the performance ot the vrork 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 Califomia, and agree that if I should
become subject to the workers' compensation provisions of Section 3700 0(
the labor Cotl iall (orthwith comply with these pmvisions.
{�..��u� Z� �//z
Gpplifam'sSignaWre �e _ _A
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNLAWPUL AND SHALL SUBJECT AN EMPLOVER 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, IPfTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrm ihat I am licensed untler provisions of Chapter 9(commencing
with Section 7000) of Division 3 of ihe Business and Professions Cotle, antl
my license is in (ull (orce and eNect. l
Lic.#_(o���S� GClass#- ��� C—Z U
�P-�'- • ��-� - - Z /.! o./ /2
Comrector'sSigBaWre ~ y-Date--^ - `-
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CONSTRUCTION LENDING AGENCY:
❑ I hereby affrm that lhere is a construction lending agency for ihe
performance of ihe work for which this permit is issued. (Sec. 3097, Civil Cotle�.
Lender's Name:
Lender's Address:
SgnaWre Date
OWNER-BUILDER DECLARATIONS: �
I hereby affrm that untler penalry of perjury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the follovnng reason (Sec. 7031.5,
Business and Professions Code: Any city or county which requires a permit to
constmct, alter, improve, demolish, or repair any slrucNre, prior to its
issuance, also requires the applicant for such permit [o fle a signed stalement
that he or she is licensed pursuan� to 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 therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permi� subjecls the applicant to a civil penally of not more ihan
fve hundred dollars (5500�.):
❑ I, as owner of the property, or my employees with wages as their sole
compensation, WILL DO THE WORK, and the stmcture 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 oRered 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
tlid not build or improve for purpose o( sale.).
❑ I, as owner of Ihe property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct [he projec[ (Sec. 7044, Business and
Professions Code: 7he contractors License Law does not apply to an ovmer of
property who builds or improves mereon, and who contrects for such project vnth
a contractor(s) license pursuant to the Contrectas License Laws.).
❑ I am exempt under sec.
Business and Professions Code (or this reason:
�'
U�wner ID verified by drivers license. ❑ Ves ❑ No
Driver's License No. Expires:
Venfication of Ownership by pype of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFEN PERMIT CERTIFICATION:
❑ I hereby certify that no excavation frve (5) or moie feet in tlepih into which a
person is required [o descend, will be matle in connec[ion with v.ork autFrorized
by this pertnit, and that no building strucWre, scaf(dding, falsework, a demolition
or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 32, Grp
2, M 2, Sec. 341, Ttle 8, Cali(omia Administrative Code).
❑ As owner-builder, I will not employ anyone to do vrork which would
require a permit from the Division of Industrial Safery, as noted ahove, unless
such person has a permit to do suc� work from [he division.
Appl¢anfs SignaWre
Division o( IndusMal Safety Permit Number. _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will Ihe applicant or preseN or future builtling occupant need to tile and
certify a Business Plan for emergency response to release or threatenetl
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the Califomia Health and Sa(ety Code requires, with some
exceptions, that a Business Plan be (led with ihe Costa Mesa Fire
Department by every business which has al any one time tluring a reported
year a quantiry o( hazardous 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 ihe applican� or present or future building occupant need to fle
a registration form for acutely hazartlous malerials? ❑ Yes ❑ No
(Seclion 25533 of ihe Califomia Health antl Safety Cotle, wi[h some
exceptions, requires registration with lhe Cos�a Mesa Fire Department by
each business which at any one time has on hantl a quantity of acutely
hazardaus ma�erials equal to or greater Ihan a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic leet of compressed gas at standard
temperaWre and pressure�.
3. Does or will the applicant or present or WWre building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? ❑ Ves ❑ No
(Section 25534 of the Califomia Health and Safety Code provides that the
Costa Mesa Fire Department may require Ihe preparation, certifcation and
fling vnth the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Departmen[.
4. If an RMPP is presently required, has Section 25534 of �he Cali(omia
Health and Safety Cotle been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future builtling occupanl require for
thB WOfk WhICh i5 Ihe Subjett of Ihis application a permit for such constmttion
or modifcation from the South Coast Air �uality Management District or from
any other air polluiion control distriGt or agency? ❑ Yes ❑ No
(Secl'an 658502 0/ the Califomia Govemmen[ Code requires [hat Ihe requested
infortnation be fumished on applications fa rron-residential building pertnits).
6. Will any part o( the laciliry to be consWcted under this permil be within
1000 fee[ from Ihe outer boundanes of a school? ❑ Ves ❑ No
(I('yes", the facility must meet the requiremen[ of Sections 25534 antl 42303
of the Califomia Heallh antl Satery Code).
7. If a permit irom the South Coasl Air Qualiry Management Distnct or other
air polWtion control district or agency is required for 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. (If'yes", attach certifcate of compliance trom the appropnate air pollution
control ofticer).
CERTIFICATE OF COMPLIANCE: I certify that untler penalty o( perjury the
information given above is correct. I agree to comply with all state lavrs antl
city ordinances regarding Hazardous Materials and Emissions.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury thal 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 conshuction, and authorize representatives of
the Ciry of Costa Mesa to enter upon the above-described properly for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permi[ until fnal inspeciion.
SignaWreofLegalOwner(s) Dale
3051-G613/0]) . .. '
And�AulM1onzedAOPll�anl �—Date
- � �'
Simplifletl 7'rr.xcriptivr Ci�rCiGoiur pi� C:
Climu«�.'Lunc:: I iwtl 3- 7
,2UOflltesirla:tL�d FfPf�Cfllir:rretiar.r C3�+-:I..lt-fil,7'-i1\'AC
S'ilrtddi6�eea: L'q1/n'cameurdA�enC� L����/�I Lu�r.: 7'en�ur C �
28Z3 13A�1D/.v LANe- —- � f5`�/`I►�"Y j Z%lO/IZ I���j�U
Enuiomenl'1'ypa� LisihhinimuniBfi'icienm� .� FinmHrr, � renuireme�� � Thennusru
❑ P�icVuiEeil Iinii . Over 4111�.of duc e
}I�f•unmce &1AFUEBOa� ❑ C�P_ Served bp s,ys�ein addeA i re )pa�in �el6�ac1�, �
OCoudeisnl�Unil ❑E�If( �OlCe,roiFUmce. /U00 rf .jmcpilAilio�iey���puce- inainllcQlL��ririn�c.ecni,mim�tf�r .. � � �
❑ U16ei L . � IL6 (CZ l. r;-.i) . . ..
/. Lquipwcnl 7�.1'pc: ChaUs;: Ilie cqmpmenl bcinp. msl;dled; if morc Ihnu auc;el'cicn�, usc wmlher CG-1If-nl.'I-,HVfiL' inr cncli.sVmem. � .
.. . � . . ..... _ _ .._. . : .. -.� . �...
. 2 Minimuni L�ipiipmeui �fllcimicicr.: 13SEEIi. 7Y'S6 APIJL, 7.711S1'P lui.typicnl remdaminl;g'siems. . . . � . -- ,
�Cmvractm�(lliicumencntiai�AutLur's_/12espuusi61e1�)esi��uer`s'UecinrationStncement) � . . _. . _
. . .: .. . ... .
� I cerliiy Ilial [his CerliGcme of Complimice documentaiion-is accuraic und complete. �� � � � � . � � . �. �. , , : �
• I nro eligible �nderpivision :i of tlm CaliPonuu Businesa un� Profcssim�s Code tu uccepi respunsi6ility for Ihe desi6ni identif�ed.un Ihis
� CeniticaleofCompliance. �� - � � � . � � � . „, _.
I cenifp IUai the ener6�tlenwre:, nntl pedittmxuc.e spccificmion: 1m� Ihe �esi�ni idenliLed on Ihis'Cerlificaie vYCompliancc conComi ln�lhe. � ---
� - requireme.nts �of'7ille.2�, Punr I aiid G of the. Calilumi�i Codc of kegulat(oae. � � � ' � � ' . . � � . ... � . . - . . �
� •. Thc desi@n features idenfiGeA.on tlus Ceriificaie of Complianec are conois�ent wiqi 16e Infortnalimi ducumented on a�he.r.,applicublc���_- ��. ����---- �� �- �� �--
. . ...... . - . .. _ . . �
c�mpliance iorm, worl•;st.��elc„culcuiation.: pluns and speciticntions.submiried�to"tYieeniorcemenl tipenc�� fornpprnval witl� tlie:p.etmjl. _ ,... ,. ...
_._. . ._.. ..... . „ ......:. .:, � .
.. ... unnficalimti . . . , . ._. _ .. . .. . .. .
: . .Name�. �% . .. . .. / . .. . . .�. . . . . . Si�,mamrd. . .. .. .. . ... . . .� ,: . . .. : .: � . . . ..-
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A�c G�...., e_ ,... .
Compan�c . . _,.. •. .. � : _ �. . . . .. . . . . . `- Uate� .. , . . .. . .
—r�r� � /1a/i� _ _
I �uoil.0 e,/ Ov+ e c,�.On��G�9�(/�t C_ . _.. ..
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'lOUil I(eridcn�icJ Cmnphuncc Forma
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II�Urr.L �01l�
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CilN�Ci'ISZ'6JAIIZL' II�I.TL-)l'T':7:TE!Y2l1t;a11�%SL�y1LJ
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Z00£� I;uilcli.n�� Guer�*}� Lf['icienc�� SC�ind.�rci�; V�e.sideni:ial T:IVAC �li�.i°.rn.i'.Inm
Gfirr<<o.Ce�. Zo�ies 7�uid l tiltrut��L % GZ'_(_, -�.asvi�,�t�'s.a�
rT1S7N��s6 ttNt> PltOr�68i0NF COnL. SL;CTIOr� �;t:�u
ldrillfni or deliherate diaragard nnd viofation nf thu buildinp, i�iti�r, mcluding thr. C�iliforniti Fiuild�m�; Cnde, und
Incnl permir reqmremenu: conFtiwtes ;i c¢uer. f'or dicciplin�vy action Frnm tha Convac�or:: Statr. L-icenxe Ilonrd
worlting in oo»lunclipn wilh lhc Vonul building departmeni. This acuon may r.om;isi nf Gnes up tu 1�.i,UO(1 i�r.r
violnuon or r+u.vpr,n,vinnirr.vnr,�uon Af a contrur,tor'; lir.r,nsc.
�n�IIGn' IS n 1'CitMI'f' 1tI6l1UASfl4
n wrucen ennau•uctinn pennu shk�l! h<�, nhcuinf;d fi•am tl�c eni'orce,mr,nt xgr,ney prior in thr. erer,tion, r,onrttuction,
reconstructiou, mstnll�itinn, rclocaeioii, nr ,il�eration tsffln, mechanrcul ayF�cm, escept as perinitted�in Appendir.
ChupCer I�, Sea�ion I l'L:2 0( lhc 1(I(17 C;�difomia lJ�ecliunicul Code. Projects reqmring, permits inr.l��de, bm arc noi
limited ta:
� New �:TVF�C fOStilll��tion
� FT\�AC Chnnpenul
• RepVacemeni nf fumucc, cuil, FA.U, or con�Senaer
• Relocltion ofan exieting I�TVA<: u»ii �
+ Addiug or re��lucing more than�hOfl ductin�+�m uncon�Ai:[ianed sp,icr.
I. Heating equipment mual have a minimum 7R%� P.FUE (Er.::eption WaII K(lnor furnace.^,; room i�eaters).
'.1. Centtal air.condifioners & hen[ purr�ps.fea� thao�6:i,00U FSmlhr musl have a minircmm t' SLER. �
?,. I�ewly installed or reniaced ducts must have a minimum insulation value of ]t-42.
'�. N sethacl: type thermostal (24 hr clocl: with four set points) is r�quired for a1Y alterations.
;. IJeu� or replacemeni ducts must rneet the mandator�� requirements of Section I.50(m!:
�� Ail joints anel openings in the in the i-NAC eystem muei be sealed.
• Only UL 1 Sl, UL 1 ElA, or UL 1 F1B approved tapes or mastic shall be, used to ;oal duct openings.
•� Connection^ of inetals ducts and the mner core of fle;: ducts chall ne mecnanically iastened. Fler. ducts
musi be: r.onnected using.i metal sleavelcoupling.
• r•lez dur,ts tna� are susoended musi be supporzed every 4f�. ma>: for iiocizon[al nmr. wrth no more than 7"
of sag henueen supports and 6 ft. mar. for venical runs.
G. Tne CI'-uIi-NIlSCEI-IiA musi be completed and sie ied'oy th:: installin� contractor. Tne Insnector will collect
this iomi and verif�� that the model numbers are the same as the installed equinment.
(714) 754-5273 • F� (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
.lob Address: 2873 BALLOW LN
Suite:
Vicinity: HOUSE & ATTACHED GARAGE
Parcel Number: 14157211
App�icant MC EUEN, MIKE
Address: 2428 NEWPORT BLVD #5
COSTA MESA,CA
Zoning:
Phone: (949)722-8846
Zip: 92672
Owner: MORELAND, PATRICK GERARD
Address JR
COSTA MESA,CA Phone:
2873 BALLOW LN Zip: 92626
Contractor: THE ROOFING SPECIALISTS
Address: 2428 NEWPORT BLVD #5
Arch :
Address:
Phone: (949)722-8846
COSTA MESA,CA
Zip: 92672 License: 734068
Phone:
Eng:
Address:
Status: ISSUED
Applied: 10/01/2001
Issued: 10/01/2001
ISSUED BY: �
Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF EXISTING SINGLE FAMILY RESIDENCE & ATTACHED GARAGE (27 SQ). TEAR OFF EXISTING SHAKE ROOF 8
RESHEATH WITH 1/2" OSB PLYWOOD. INSTALL 30# FELT UNDERLAYMENT & REROOF WITH "ELK" 25 YEAR
COMPOSITION SHINGLES.
Plan Check: $0.00
Permit: $125.25
SMIP Res: $0.55
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $125.80
SETBACKS
MAINSTRUCTURE Front 0-0
ACCESSORY Front 0-0
PARKING Ezistin : o
NOTES:
Rear 0- 0
Rear 0- 0
FEE SUMMARY
Calc Valuation: $s,aes.00
Claim Valuation: Sspes.00
PLANNING & ZONING
Left 0- 0 Right
Left 0- 0 Right
Required: 0 Proposed: 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, § 7, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authonzed under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final epproval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
zaae�as �sroo�
WORKERS' COMPENSATION DECLARATION: �
I hereby anirtn untler penalry of perjury one oi ihe followinq declarations:
❑ I heve end will maintein e ceniticate oi consant to self-Insure for workers' compensation, es provitletl for by section 3700 of ihe Labor Code, for the pertormence of the
work lor which Ihis pertnit is issued.
I'heve antl wiil maintain workers' compensation insurance, as requiretl by section 3700 of the Labor Gotle, for Ihe peRormence of the work for which this permit is issuetl.
—My workers' co�nPensatlon Insurancg carder end policy number ere:
Policy Number: Z� �— � �
ef one
❑ I certity that in the pertormance of the work for which this permit is issued, I shall not employ any person In any manner so as to �ecome subject to ihe workers'
compensatlon laws of Calitomie, and egree thet If I shaultl Decome sub�ect to Ihe workers' compensatian provislons ot Section 3700 of the Lebor Code, I shall forihwith
comply with thesa provisio �s. � ('�
MP���_a��� Si9�aNre:��1 —t7/-1-I�'�:1M " Date: –��l (�l � h 1 �� i
WAFNINQ: FAILUiiE TO SECURE WORKEiiS' COMPENSATION COVERAGE I�HALL SUflIEC� AN EMPLOVER TO CFIMINA� P NALTIES D CIVIL FINES UP TO dJE HUNDRED
THOUSAND DOLLr1RE (5100,000�, IN ADOITION TO THE COST OF COMPENSATION, DAMAGES AS PflOVIDED FOR IN SECTION 3]fI80F THE LABOR CODE, IMEREST, MIO ATTORNE`fS FEES.
LICENSED CONTRACTORS DECIAflATION:
I hereby aXirtn ihabl�eT Ilcensetl under provisions of Chapter 9(commencing wilh Section 7000) oi Divislon 3 of the�Business entl Professions Cotle, and my license is in tull
foroe antl eHect�Li` c. NI iCless #� [ 3 9
ConiractorsSiq'neNre � A �� L. Oate: I t�T�/e �
CONS7RUCTION LENDING AGENCV:
❑ I hereby aHirm that there is a consiruction lending agency for the perfortnance oi the work tor which Ihis permit is issued. (Sec. 3097, Civil Code).
Lentler's Name: Lenders Address:
Signature:
OWNER•BUILDER DECLARATIONS:
Date:
I hereby ettirtn ihat untler penalry of perjury ihat I am E7(EMPT FROM THE CONTRAC70R5 LICENSE LAW for the tollowing reeson (Sec. 7031.5, Business and Professlons
Code: Any ciry or counry whic� requires a pertnit to conswct, alter, improve, tlemolish, or repeir eny simcture, prior to its issuance, elso requires the applicant 1or such pertnit
to ille a slgned statement thet he or s�e Is Ilcensetl pursuant to the provisions of Ihe Contradors License Lew (Chapter 9(commencing with Section 7000) of Division 3 of the
Business end Professions Code) or ihet ha or she is exempt therefrom end ihe besis far the ellegetl exempiion. Any violation a� Saction 7031.5 by any applirant for a permt:
sub�ects the applicant to e civil penelry of not mo�e Ihan five hundred dollers ($500)J:
❑ I, as owner ot ihe property, or my employees wlih wages es their sole compensation, WILL DO 7HE WORK, and the structure is not Inientled or oflered for sale (Sec.
7044, Business end Protessions Code: The Contractors License Ww does not apply to an owner of properly who builds or improves thereon, end who does such work
himself or hereelf or through his or har own employees, provided ihat such improvements are not Intendetl or oHered for sale. If, however, Ihe building or improvement is
sold within one year ot completion, the ownar�builder will have ihe burden of proving that he or she did not build or improve tor purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to construct ihe project (Sec. 7044, eusiness end Professions
Cotle: iTe conirectors License Lew does not epply to an owner ol property who builds or improves ihereon, antl who contracis br such project with a comractor(s)
license pursuant to the Contractors License Laws.).
� I am exempt under sec. Business and Professions Code for ihis reeson:
Signature: Date:
Owner ID verified by tlrivers license. ❑ Ves ❑ No Drivefs License No.
Veritication of Ownership by (type of tlowment, i.e. - propeny tex �ill or tleetl):
Expire5:
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I heraby certify Ihet no excavation tive (5) or more fee� in depih into which e person is required to descend, wlll be made in connection with work euthonzed by �his
permit, and ihat no builtling structure, scaHolding, falsework, or demolition or disman�ling thereof, will be more ihan thirty-six (36) teat high. (Chap. 32, Grp 2, Ah 2, Sec.
341, Titla 8, Califomia Atlminis�retive Code).
❑ As owner-builder, I will not employ enyone to tlo work which would require a pertnit from the Division of Intlusinel Sefery, es noted ebove, unless such person has a
permit to do such work from Ihe division.
Signature: Date:
Division of Industnal Safery Permit Number:
CERTIFICATE OF COMPLIANCE AND AUTHORIZA710N OF EMAY: I certity under penalry of perjury that I have read thls application antl state that ihe iniortnation given is
correct. 1 egree �o comply wlih all state laws and city ordinances relating to building consiruction, and authorize representatives of the Ciry of Costa Mesa to enter upon the
ebove-descnbed properry for inspection purposes. I agree not to occupy or allow occupency of any building euthorized by this permit until fnal inspection.
COOE I, INSPEC710NTYPE
1616 Fixed System Final Fire Prevention
1266 Pool Spa Final
200 Final Re-Roof
201 Final Blak/Retaining well
202 Final Factory Fire Placa
203 Finel Sign
204 Final Demolition
p0g irrtrtia�s
1� Q �
COOE� INSPECTIONTYPE
206 Final Mechanical
208 Final Plumbing
210 Final Electrical
212 Final Flre Preven�ion
220 Final Planning Approval
222 Final Site
250 Final euiltling/Occupancy
PAIE IximALg
� ' �,� ���;
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 917 COBTA MEBA. CALIFORNIA
�For Applieanf fo Fill In Complefely
TYPE OR PRINT
COSTA MESA CALIFORNIA
rtt Kt�tivtu
Lot 56� Tract 201�, Plan 2-CR
o gEp � i :"+1 �INANCE DEPT,
' \�/ CITY Of COSiA MESA
��
APPLICATION FOR PERMIT
BUILDING
For Office Use Only
0.ELE�PT NO. I w PQRµjT�NO..
OY I �P'J� !� 9 I I SEPE IB�U'C
o - �o
TEL. BUILDING
NO.(�R �Iii9/1 pODRE55
iE�. COSTA MESA, CALIFORNIA
No. nR 't1�99n
—,. —�e
FIRE
ZONE TYPE GROUP
APPROVED
81ZE NO. OF BLDGe.
oF �or ��nn .� F now on �or��
USE OF
EXIBTING BLDG. n2
88TBACK LINB PROM
CHMBM oP eTReEt � �� REAR YARD �
SIDE YARD I LE� O� I RIGHT fj � -
DESCRIPTION OF WORK
BUILDING p r NO. OF
SIZE �u � X'J�. � ROOMS
PJCTERIOR WAL4 St.UCCO ROOF
garage
ZONING
ZONF� —� NO.OF lISE OF
V` ` I PLAN6 �� �BO�LDID
LEGAL �.1�ih �/.� i. [
YARDS
APPROVEO
ICENTER LINE 8TJ
FRONT S I
R.SIDE �
L. SIDE �
REAR 33
A�vPROVED � /� .
A
i HEREBY AGKNtlM�LED6¢ THAT 1 MAVE REAO THI6 APPLIGTION }HE AMOUM BXOWN UNOER VALUATION 16 FOP THE
ANO BTATE TXAT �XE ABOVE IB CORRECT ANU AGPEH TO COM- pURPO6E OF 6BTABL�9HING A PERMIT F5E ONLY.
PLV WITX ALL G1V OROINANCEB ANO BTATE LAWe q66ULATINO
6Uq.plN6 CONBIRpCT10N. YALUATION
SIGNATURE OF PERMIT FEE $� Y —
PERMITTE �j �j
�Y � � � N � �� $ ���71 ��O PLAN. CHEGK S I /
F
C
O
LL