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HomeMy WebLinkAbout1642 BEECHWOOD - Building Permits • l .. F 9 CITY OF COSTA MESA 4 BUILDING DIVISION > •j •,,,,- , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 0. /s • PERMIT "►R-'ty> ernso 0. 7301-00253 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 1642 BEECHWOOD Status: ISSUED Suite: L,C;T 'g i Applied: 02/23/2001 Vicinity: PLAN 3 Issued: 03/22/2001 Parcel Number: TPN00063 Zoning: _____a___ Applicant: PHILIPP, ROLAND - . _7_ _ ISSUED BY: Address: 1565 W MAC ARTHUR '�C� = - T . I - ---� COSTA MESA,_CA' . /122.- - ,TT�P-hone , 7114-668 0 �-- �� - A C' -A 1 ( Zip: 92626 i -.-.„--; /rr �1 A 1 t' - - .J / . / -`7 ,-'"A� • .\ Owner: STANDARD PACIFIC+HOMES' _ --- - -- -� Address 1565 W MAC ARTHUR - -= , ,•` •�� (C///OSTA MESA,CA/�- Phone: 714-668-0300'� �� ��. �N , ''"--N �Z� r N. / ,' \/�,� Zip: 92626 %-<:1*-'` \�//1 7) \ Contractor: OWNER-BUILDER \;‘,\,\N / essn j�/ \ \� > \ /UgG? /4-7Phone:„• ,' �A P' •License .0'• - Zi F ( ) //2/ I .al , _. I\ l r"----\ ' l 1��—_11 f _ �_ T ri / I)Arcti(.`-BASSENIAN;AGONI z.-! ) iV` �� .a - j Eng. rAddress 2031 ORCHARD DR t .7 - "Address. l STE100 i_" .�i° Phone: 949-553-9100 - \ ,,S/ Phone:`. i��' r� NEWPORT BEACH CA � �"/ ��sr�v' .---- I X11 Zips 92660 A,vLicense: f UI Illfr'I _ .- - _ _ h1 i "I t—� 2 l '''1,I7 r/',SCOPEOF'PERMIT'L'7'7` ' 1` Iiia ;l , y „ tI ,AV ����11 � � 0 CONSTRUCT NEW SFR,PLAN 3,FOR STANDARD PACIFIC HOMESr2972SF LIVING;579SF,GARAGE,20SF COVERED.--_i ENTRY AND 133SF PATIO.� I 4,,,, - u/I REF:soo'i 37-- Itl • -�p _ rt ,; / \ ter: `� l � �� u ' - FEE SUMMARY/7 T 'V'I � J /f/' IPlan-Check: \I)$316.19 I L Calc Valuation: $269,922.26 %\ Permit: $1,945.75 Claim,Valuation: .C , gtl.ol) SMTP Res: `x$26.99 1/ _,,,c --" I JJ SMIPCom $0.00 ii \Other. $000 t 1 j Inspection: $0.00 � ', °a � . �, 1 �/ - Tnoo-" o �" /J o0 o n -a•px=y,-",/i- 4 f� `U.'fi'�.Gf yy_. O`7 ace? L'1 ;r'CS�� // am'-�� Y,-� 3-i Total: $2,288.93 -, O0 (: 9''' o'0 " - 0 \\�� i !/.)\ �, o 7)%5) to n c��� n���_ oe o� ( U v ��o � �� �` PLANNING•&zZONING�/ � % SETBACKS �� _ - �� MAIN STRUCTURE Front-- 16-0 /Rear 1-0 ( Left 5-0-3* Right �5-0-27 0, ACCESSORY FroM 0 Rears 0-0 ' 1 ' -'�eft 0-0 r-^��•-J RI ht� 0 0 PARKING Existing: 0 Re aired: 3,,,-_:..._ _ Proposed:- 3Ocr-) ' 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 2446-46(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 workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it 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 15 UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class# 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: 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.). 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 exempt under sec. Business and Professions Code for this reason: Signature: Date: J _' 0 Owner ID verified by driver's license. CI Yes ❑ o 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 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 application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 0 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 0 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. • na Le IOwner(s j .cDate And/Or Authorized Ap icant Z� Date CODE CODE t. INSPECTION TYPE gaff,' 1NTIIISLS CODE! INSPECTION TYPE DATE INTITULE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place - 220 Final Planning Approval 203 Final Sign222 Final Site 204 Final Demolition 250 Final Building/Occupancy � ��r r.w-.Lo-cwa w.-s rOu.A1•41fl' ut1.LC1l I a1J JJCIO 11X (19C770C10 Y03e1'001. • FINAL GRADING CERTIFICATION Project Address: 1 4c i AwtS Lot Number. 11 7tvitati k H /Se 15es z Permit Number. Gt two-coo 3 z By Civil Engineer: I certify to the satisfactory completion of grading in accordance with the approved plans, specifications, local and state codes: All drainagedevices required by the grading permit, grading plan and grading ordinance have been installed. Adequac.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 valis. 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 designed elevation ,1 Supervising Civil Engineer v` Reg. No. 39 428 %/s (Siguwle) I Date LI Welt • 9•3t.at tr4teoFcat� Continuous Inspection&Materials Tewin SOUTHWEST aa.aSSSSSSS ►aaaa Inspection & Testing, Inc, 10826 South Norwalk Blvd., Santa Fe Springs,CA 9067( (562)941-2990 • (714)526-8441 FAX (562)946-002t Building Official November 13, 2001 City of Costa Mesa Department of Building and Safety 77 Fair Drive Costa Mesa, California 92626 Re: Final inspection for the Mesa Verde Collection,Costa Mesa CA Tract 15882. Building Permit Number Building Permit Number 17 601-00249 24 B01-00246 18 801-00244 25 B01-00241 19 B01-00255 44 801-00254 20 801-00248 45 801-00188 21 1101.00253 46 1101-00252 22 801-00242 47 801-00247 23 801-00251 48 1301-00197 Dear Building Official: Southwest Inspection and Testing was retained by the Owner to provide special inspection and materials testing in the arca that swat req: by section 1701 of the Uniform Building Code,approved project drawings and specifications,this work was witnessed by the following special inspectors. • Concrete placement was observed and oomptentive strength samples were cast by,Pat Osterman(ICBG#106152581),Roy Lyndsay(ICF #503699849). Compressive strength samples were picked up by Southwest and tested in our laboratory.' All work was done in aocrdanc with the project plans,specifications and workmanship provisions of the Uniform Building Code. Stressing of W post tensioned tendons was observed by Roy Ward(OCEMA#0288).All work was done in accordance with the project plans,specifications and wuticmanship provisions of the Uniform Building Code. Based upon special inspection and materials testing written reports of this work,it is our judgement that the inspected work was pe forma the best of our knowledge,in accordance with the approved plans,specifications and applicable wcxt utanship provision of the Uniform Building Code. eviewed By: A4 President tom{ p 1 SLG e. • .kdg ,riap, 4-3/•4Y / Tuesday, November 20, 2001 2:23 PM Gary 8 Diana Shouse 702 396-5188 p.01 /9. STRUCTURAL OBSERVATION GROUP GARY E. RUBIN 2249 AVALON STREET COSTA MESA, CALIFORNIA 92627 Pager: 949/2274668 Billing: 7021396-7758 E-Fax: 118661732-6429 Billing Fax:702/396-5188 County of Orange. Planning& Development Services Department Bulling Inspection Division 22921 Triton Way, Suite 125 • Laguna Hills, CA. 92653 Report for: Mesa Verde Mesa Verde & Adams Costa Mesa, CA. Contractor: So Cal Masonry Structural Observation Grout)was retained by the Owner to provide standard inspection and materials testing in the areas that were required by the approved project drawings and specifications. Observations of Proto II Walls and Middle Walls of Lots 17-25 and Lots 44-48 were done by Gary Rubin (#75823,#78733 ICBO). All work was done in accordance with the project plans, specifications and workmanship provisions of the Uniform Building Code, and in conformance with the Structural Engineers' recommendations, approved drawings and/or revisions,project specifications and applicable workmanship provisions of the Uniform Building Code. -÷Cres.4.-+ Gary E. Rubin Structural Observation Group Owner GER/ds p ' - CITY OF COSTA MESA ' 4 BUILDING DIVISION F • `- ,i ': DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 4 PERMIT 41kbe I, MO1-00130 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 1642 BEECHWOOD Status: ISSUED Suite No Applied: 03/14/2001 Issued: 03/22/2001 Vicinity: PLAN 3 Parcel Number: TPN00063 - -- "- -- ISSUED BY: mss! Applicant: PHILIPP, ROLAND(�-<-' cn 1 r----'1, c�_�" , Address: 1565W MAC ARTHUR"'_ \ ' 3 f ;� `'�-----c-n; i.�,\� /nr// ' I c, i' ' � -`"� COSTA MESA;'CAA '-- _\ Phone: 1714-668=4300 AJ " �`) \��N /- •,›„=,-,-------„.„--,,--,,,, /"� ` /��=_Zip`_92626,-,- „ \�\.� \\'�//ow)/:/rte-- - Owner:na STANDARD PACIFIC:HOMES �������:`,>- / Address: \7565 W M( \ ACARTHUR ��‘ �� '-v� /r ril C ///%i/ Q 4O%EflDER COSTAMESA;CA Phone: 714-668-4300Zip: 92626 �` \;4.. �� ��Address. ' ///7217.-"---7%71 l� I. r .,,� P 11 II 11)�,- 1 �� r''; I 2.3,-‘t-Rhone: ' 1 `I _ / r//l i,'J 1 ---C ,' zip -- 1c ^\ ��;', `.;t\1i \; �.\ � A �(=.� �f- �._ License: 0 j° \�‘"T/\)) . L.�-) V� s f 6I Arch/Eng ii(.1 of \i,./- - ��t i'i I o, /Address:,'l1 � i ki, l I (1��I ,l / �_� /T-qT/ ,lrn�� /f'Phone: r11/��i�//'i /� 7�(� �:1 � le VGI / i'o i L . 11 ;.� „ �._!/1.(zip: .L ;t It. 1 LAV if. A]i i r 1 A 1��' )\�Ok 1 -- - _ License:- - - - - _-- �' � t T J `�++\ G ;�"- _,(SCOTE OF PERMIT'' %LE � I)\\CONSTRUCT NEWSFR:PLAN 3 CD i�, C) \GARAGE,2 SF COVERED ENTRY, 1FOR-STANDARD 33 FT PATIO = A IOORD PACIFIC///ES 2972SF,LIVING,579SF Cm `A��/ 2 FAU<100K BTU, 1 FACTORY FIREPLACE, 1 HOOD W/MECH,EXHAUST, 1 VENT FAN/SINGLE 'D\`,2 COMPRESSORS UP TO 3HP/100K BTU.REF:601-00253 c� \` FEE�SUMMARY s�� vl 40/ \ 2 �v �/ \\ D ��o i Quantity .,; �' '' ,.., n cs r,4,. Quantity ISSUE FEE <J" \�$23 50 o;',;' o ou Repair/Alt Absorbtion Unit .1_/I?$0.00(0yb0" Inst FAU<100 KBTU 1N \ $29.60,4',2.-0n � 00 c6,-- �3,„Repair/Alt Refrigerabori'U_nit �-�J $0.00(j I Inst FAU>100 k,BTU \ $0.00, 0 n ➢ U G EP, Ventillation,Sistem " $0.00/0 Repair/Alt Cooling/Heat l $0.00�,p ° % . - v �-- �, J e % 0 C' ono o Evaporative Cooler $0100 0 Inst/Rep. Recespall,Htr $0.000 0 o p` �o �, Commercial'lncinerator $0.00 0 Refrig Sys>100 k BTU��7$0.0000`� � ,0 0 Co plessorsiAbsor /� Q/$0.00 0 Refrig Sys>100 k BTU (\($0.00 0 `-�.;_CdCompressors'/Absorption'Syslems Gas Piping $OA0> 0^ ----7--- __ . �Upto 3'hp/100.k.BTU \\`"�%� i $29.40 2 Factory Fireplace $10.65�` f "1 _3 To_15 hp7:500 k BTU \,)v 29 $0.00 0 Hood w/Mech Exhaust x$10.65 t1 Cj (t ' ri 1(` 15 To 30 hp/,1,000 k BTU O $0.00 0 VAV Box $0.000` ��',�j ., ci 11301To 501fip/1;750 k BTU,%/26-1 $0.00 0 Vent Fan/Single Duct $7.25 -1- 1�S l :'Over 50 hp/Over-1;750'!BTU $0.00 0 Appliance $0.00-.<0.°--)c)-,;,-----_'c ) Boilers:-_,-,-_ ' Fire Dampers $0.00 0 - `-_o� O<Upto 3 p - $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> 10000cfm $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 rrinnnnrtiTc r cotrIAL rQ"1D'TiQ iS 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. 7 FOR INSPECTIONS CALL: (714)754-5626 / 2446-46(6/00) // ,. C 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: r 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 AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEYS 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.# Class# 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). 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 end 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.). XI,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 exempt under sec Business and Professions Code for this reason: Signature: Date: 3(27 0 Owner ID verified by drivers license. ❑Yes 0 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: 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? 0 Yes 0 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 0 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? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application ap.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 IL 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 ❑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. Si�ure Of e l O n r(s)Of a I��r(s) /� �ate t`I And/Or Authorized Applicant // Date CODE 4. INSPECTION TYPE PATE' INTMALS CODER INSPECTION TYPE DAA, I( �AL�S 1616 Fixed System Final Fire Prevention 206 Final Mechanical 11-2L -01 4 11Y 1266 Pool Spa Final . 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 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 Building/Occupancy FCITY OF COSTA MESA BUILDING DIVISION >:J ..i . DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER t: PK/ . PERMIT o di' /P01-00145 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 1642 BEECHWOOD Status: ISSUED Suite No Applied: 03/15/2001 Issued: 03/22/2001 Vicinity: PLAN 3 t*...,___ --Parcel Nunmber: TPN00063 _. ^C� 2_ -__ -?_ ISSUED BY: Applicant: PHILIPP, ROLAND' ` l"\ ' I ?\\; �� / Sz. Address: 1565 W MAC ARTHUR /, �r �� ''� /0,COSTAMESA, CA .� \ ` Phone 714-668-0300- 7, �/i ri C \ N r- Zip :92626 -- - ` 1- /� ).,,, N_ s,--\, Owner: KSTANDARD;PACIFIC HOMES V• \\''.`\\ � / 1j/ /id/!,/ .. �A,/'- Address 1565 W,MAC'RTHUR ‘.\; N / /'� /2 COSTA/MESA,CA Phone: 314-668-4300 \-,.::,1\1�� J2 I, / / ���f`F Zp�C92626 \1\ �. �'U / 2, �f ��i� , ��� ,`!� f f�(J i_,� - \ C, /\ } l�� fi ; 1 -� / I�ontiactor �OWNE,R-BUILDER, , /'( l t\� �� ,,, , t�'i 'Address: i'/ J • r .--c..9,, - --!A, �^ /z,y �, �� 1� ,*i/ 1(,1�' I V�' Phone: �l�d/ v, ,._�,)� i -- � o �� i.� I 1 1 fl \7---, Zip: 1 �: ;i10<--"; - - License 0 - - - - _ i �� 1 (---� I 1 , , ( r n' rn 7,,,-„)i -c r - r r '9 `,\ ! ,� // ll; (A(rch / Eng I() ‘..‘,....../t. i�4[ A. - I LI ��? /1 �, i Addres \ut\ I - - JI \ � -� _ �r C. 3% �) ,'-- s. ° ._-Z�p •-- - // J - �,I J . .- License: - ' �/ �� \P SCOPE OF PERMIT 1" CONSTRUCT NEW SFR-PLAN 3-FOR STANDARD PACIFIC HOMES:2972SF LIVING,5795F ,�\ GARAGE,20SF COVERED ENTRY, 133SEPATIOT3'.BATHRUBS, 1 DISHWASHER;1 EXPANSION TANK, 1 GAS:(.1';4 OUTLETS),2 GAS OUTLETS(OVER4), 1'LAUNDRY TUBANASHER, 1 PRESSURE/ REGULATOR, 1 SEWER CONNECT;1iSHOWER 1:KITCHEN SINK 1 SERVICE/MOP SINk/i WASH BASIN 2-WASH BASIN SETS 3 WATER CLOSETS'1 WEER HEATER°1tWATER SERVICE. jy REF:1301-062 ,e;„ /01 00253�,e„„'' ° •lel ,);e �t1.7 �Lhao ": ©mc:..tQ�/�(,/ fr, \01 !/, `moo ,0°,FEE:SUMMA`RY°a• : C / `QU \AM7 QT.Y ``�,`` -x �AMT��TY (6)\-21 /0 AMT QTY ISSUE FEE $23.50 r�.,LaundryTub/Washer $9:80 1 Sumpx)12 $0.00 0 Backflow irrigation $0.00\ 0, / ',andscape Irrigation-Y$0.00. 0\ �Swimming-Pool $0.00 0 Backflow Preventer $0:00 X7,0 i \-0-tapir,--- 1 S$o.00�0,\ trap Primary $0.00 0 Bathtub $29.40`3 Pressure Regulator'J, 1----‘ $9.80 G'1 Urinal% $0.00 0 Clarifier System $0.00 0 -O\ Process Piping(percl01ft) $0.00 ----0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 O�C`.Receptors $0.00_ --0"%// Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 �SeptioTank=r-; C=a$0.00�0�---//Wash Basin $9.80 1 Dishwasher $9.80 1 Sewer Cap for-Demo $0.00-- 0 Wash Basin Set $19.60 2 Drain,Floor $0.00 0 Sewer Connect $24.65 1 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain,Roof $0.00 0 Shower $9.80 1 Water Heater!vent $52.30 1 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $9.80 1 Gas(1-4 outlets) $6.15 1 Sink, kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $2.20 2 Sink,service/mop $9.80 1 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand AIM) sn no n • NOTICE: The work authorized by this permit shall comply with all applicable handicap access rigaT)Akei1/446 rAC tFEE5lta$235.40d related regulations.(Ord. No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically exiCONBEITSJAREGIALretObingillablathin 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 ii - 2446-46(6/00) 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 carder and policy number are: Carrier: I 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($106,000),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.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: 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 far a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,es 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 .. 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 exempt under s Bu ' ess and Professions Code for this reason: Signature: Date: 3'L) C� Owner ID verified by drivers license. 0 Yes 0 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 thirty-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? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 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? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification from the South Coast Air(Duality Management District or from any other air pollution control district or agency? D Yes 0 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 0 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? 0 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. Sign re qy Ly al ner(s) /u' /6(Date And/Or Authorize pp(cant (/ Date CODE f INSPECTION TYPE PATE' INTITIALS CODE f INSPECTION TYPE DAIS INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing Maio 01 -KT. 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 ` CITY OF COSTA MESA 4 BUILDING DIVISION > • Tr .,� DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER %I w.._•.•-�>a ! PERMIT �� "i Y `01-00200 u,o..9`e (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 1642 BEECHWOOD Status: ISSUED Suite No Applied: 03/14/2001 Vicinity: PLAN 3 Issued: 03/22/2001 Parcel Nunmber: TPN00063 Applicant: PHILIPP, ROLAND - ISSUED BY. Address: 1585WMAC ARTHUR - _,c �( - l �--� -�c��_;` COSTA MESA,CA-' ..---c__-, iPhone: 714-668-4300; ��' i ,�� /„��'% - A 1 Zip 92626 rV ,// / ...� N'-v. Owner: OSTANDARD,RACIFI HOMES:" --���A���/V�� -� v /557/5 r R �� _' O '� /./ /� Addres1565 W MAC ARTHUR .\ V is ,< ; j/t it t COSTA M/ESA,-CA i' Phone: 714-6684300 \� ^ `� `''/ \`,,��/,�' / Zip: 92626 \‘`',.\\<, ,�� (C/ftiontractor. O/WNER-BUILDER ! la P A �� i. : . t 1 Vit I A J / / ) ,, �t -Y,,.ot; z� )V� /J ^c2 f .��, '\,,:::> License: 0 ' �1r �\I,. ��� �4 ^ I J 4O� :: r 't i f �I�Q'__= % ffl7r' ',;7 SCOPEOF'PERMIT / hT 7 7 IVa -10(I �J 1 1 � �l r CONSTRUCT NEW SFR_PLAN 3-FOR STANDARD.PACIFIC'HOMES:.2972SF LIVING,579SF I ,I'�GARAGE, 20SF COVEREDENTRY, 133SF PATIO:-- -- - -_= = �', 1 i - 11 NEW RES(1 UNIT),2 LIFHT FIXTURES,3 OUTLETS,2 SWITCHES;r1 MOTOR TO 1 HP. REF: �� �I \,\.1 J �� X1801-00253 T ligi o \ s %,, FEE SUMMARY/ �7 � �� • Quantic _-,.. Quantity,/ -'t j" �` \\ Y -_J J ( Quanti \l l ISSUE FEE S\ $23.50 Temp DistSystem7 Lighting $0.00 0f€9, /,)((• Temp`service test \�?, $0.00 \ ,. ) Busway/100 ft .$0.00 f0 ryRes.a/c package/ \\�l$0 00 j 1 Standing Section $0 00 /-',0 V. New Res(112,units) \$166 43 2972 j Misc Electrical Equipment $0.00 7 0 0 New Res(3+units) 7 \60:00 0 , ?` ..-"6.--'‘: Transformers up to,1 kva/kw . 60.06/ 0 n Pool/Spa �\ ``A` $0.00'o. I-a,,,0 w'".t''.' )p J ° up to;10 kva/kw $0.00 0 U Lighting Fixts ,,r),62'.20... ,..2."..1-: 0 0 2 dui `--' up to 50'kva/kw• -,. $0.00 /•V0 U Recept Outlets //r$3,30 ��3 ' 0,i 'o" ,-.2 "12'l up totl00.kva/kw $0.00 O.) �(/ Switches C/ $2.20 2�c o 00 0' ° °" °0 - over.100li a/kw�$0:001 C 0 /t/, Non Res Appl �C$0.00_,0��` " .,gLow,Voltage Equipments $6:00 GO7)V Res Appl $0.00 0�` --_,Low_VollpringSystem/Ckt1�$0:00� 0m�- Service to 200a „ \$0:00. O 0'`- _,Misc:Conduit` ///, Service to 1000a $0.00 0� f-`-' _ Milo.Conductor c0� �S$0.00�" 0 , Service over 1000a -$0:00„ Gik .' r/'-1 Imo)Circus(gen or ride) ) $0:607/0 Motors to 1 hp $4:75\ 1 ( ,� I Circus('me.q'h ride or.lights) / $0100 0 Motors to 10hp $0.00 " S 0,- �--J r 1'\ChritmasLTree`Stand. $0.00 0 Motors to 50hp $0.00 \0 c.3 FireworksStandc09i $0.00 0 • Motors to 100hp $0.00 0-- -..r=._3S-yOther"Electrice1;F.ee--- ` $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 /// 244646(6/00) // DECLARATIONS • • i. . 1 \ i 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. O 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 et 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 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.# Class# Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: O 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). 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.). I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions :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 s Business and Professions Code for this reason: /♦ Signature: Date: 1-4/,--12 / Owner ID verified by driver's license. Yes 0 N 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 thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). O 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? 0 Yes 0 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 0 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 tiling 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? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 011 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? 0 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 allot the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No B (If"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATIONOF 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. kSi tutureL�Of(Iteae(Owner Date at And7O�Authorized Ap I ant Date CODE r IN$PEOTION TYPE PAL' INTRIALS CODEI INSPECTIONTYPE DATE =NS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing �/ 200 Final Re-Roof _ 210 Final Electrical /��/i!'-9/ 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 '