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HomeMy WebLinkAbout1638 BEECHWOOD - Building Permits • c . - • CITY OF COSTA MESA ' 4 BUILDING DIVISION > %'4 . • DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER V. PERMIT dikbkr•operne.4. 101-00251 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 1638 BEECHWOOD Status: ISSUED Suite: tar 2„.3 Applied: 02/23/2001 Vicinity: PLAN 3 Issued: 02/23/2001 Parcel Number: TPN00065 Zoning: Applicant: PHILIPP, ROLAND ' - -- ISSUED BY: __7:5Fr Address: 1565 W MAC ARTHUR---;7--2(%=- -- -, - - -f-_,-*_ --) `-- COSTA MESA, ----- „ --",,,'?2".. CA-/ '— T Phone:1 714-668-4300, - -�----r,,,>`:',-.?7,-` .,,�%.= ')----\ i ; I l / ' ( ! Zip: 92626 owner: STANDARDNPACIFIC'HOMES - A. j1 �, :‹T:`';'-:::- 7N Address 1565 W MACARTHUR„,/<j - _ ;▪ - '- „-` �� �-, , \-v.,:1\ ViTA � 1 ii - 0 _A . COSTA MES ,7121 �_- Phone: 714-668-0300 --- :‘,.',\::"--.--,<>„,,-.. t��✓ \ \ ����/\ ////����/J�/ Zip: 92626 \:� \ J ��� Contractor: OWNER-BUILDER '. ' ' / 0` Address? %n/ `� l,,-� - ��� /c// � 7/ Phone:,-, \ \\\‘ 1�� ,Zip: / /I// J///�/ -l:icense: '0A �y t o i_____ ( � Arcti i "BASSENIANIAGONI CiC 1 `Eng: • i �� ( `sir ir• 'l - � ��� r . ,_ - � I r. \\ V�/) r Address: 2031 ORCHARD DR' �! �0, - - - • -'Address: ' ' C �` Lv� STE1,100 �.- , - Phone. 949-553-9100 Via/ Phone: r, � r\ NEWPORT BEACH,CAT _-t% �\°'-I�''.', -'"`} (� ' a \ ' J Zip:_ 92660 ' \ License Vi License:; . IOf i 7 ( l?J( / 11).J , 'I N I ; --/ v (7"'"7 % , SCOPE'OF PERMIT' i`-l1 7 ' ri ' 1� 110;=�, l � r _�� � ,k > C� �, i�l�i[1 Cl[ I c)I CONSTRUCT NEW SFR, PLAN 3 FOR STANDAR_D_'PACIFIC H_OM_ES 2972SF LIVING,.579SF GARAGE,20SF.COVERED i ENTRYIAND 133SF PATIO,V ,�� I /11 j/ REF: B00�0`1537— n( > '�l Q 111 , _ r\I 4 fl~i `,—/\ -\ - `�,- ''-1-/_\ -v---/ R-'�..'//, ice_- �l� (Alii 1-- -1 (� U U :, IFw,- _ FEE'SUMMARY/ 1 �Plan(Check: x$316.19 /' Calc Valuation: Czss,92z!z6 � Permit: $1,945.75 / Claim.�Valuation: � sosoo SMIP Res' x$26.99 _ I ! SNAP Comm: $0.00 • .,•� ?Other. $0,00 ,( =` �%t- ;% / o o � ▪ �+-tea= �,� * / Total: c1R �0 �7, °o �n° D'0:e70oX"� ✓� 400 � v� V PLANNING'&•ZONINGS �U \ \,\.-s_.\ � �C �' SETBACKS 7) ^�--”" -= �(� BOO MAIN STRUCTURE Front' 16-1 ,1621-0H- Left 570 Right 5-0 ACCESSORY Front 0-0 .Rar/ 0-°-L-.-i---It \\lCLeft 9_0 L_ - _)\A _ Right/2 0-.0 PARKING Existing: 0\"Required:- >3-- -___ Proposed; -732 - ' 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 / S 2446-46(6/00) \/ • DECLARATIONS l ) WORKERS'COMPENSATION DECLARATION: • • I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will Maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) in 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 COI t ARE($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.It Class II 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 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 o e: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 imd r sec. Business and Professions Code for this reason: Signature: s Date: tJ o I` Owner ID verified by driver's license. 0 Yes 0 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 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 ❑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 0N (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? U 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 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. • atur D. Qf g wner(s) 3 , 3 :O 1 And/Or uthorized Applica rate CODE 0 INSPFCTION TYPE . PATE' . JNTITIAL$ CODE INSPECTION TYPE DATE 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 Well 212 Final Fire Prevention 202 Final Factory Fire Plebe 220 Final Planning Approval 203 Final Sign 222 Final Site /I�!� 204 Final Demolition LJ7� 250 Final Building/Occupancy I V � rw-lo-Cw1 w.”1 rn4J1.41.r1\ IU: f14C=WClu r.eel'001 FINAL GRADING CERTIFICATION ' Project Address: 1 to 4S is-NONIAA.S Lot Number. e1 TtNZCL9C 25. 71(.141.--115 z Permit Number. Gt oo—000 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 drainage devices required by the grading permit, grading plan and grading ordinance have been installed. $4equac.provisions have been made for drainage of surface water from each building site. The minimums are: • i 2% Fall from structures within 5 feet from exterior walls. 1% Fall for asphalt surfaces and landscaped areas. 0.5% Fall for concrete surfaces to approved disposal areas. The final monuments as shown on the recorded tract map were set. All final grading dna- dons are within ± 1/10 of the designed elevation j I • Supervising Civil Engineer Reg. No. 3941 /s (Signature) Elate 1,it/1010) 1. I • r,c #14 (:AAL �OFCAL0u' --S Wes* • It Continuous inspection &Materials Tessin SOUTH[VVEST SSSSSSSSSSSSSA Inspection & Testing, Inc. 10826 South Norwalk Blvd., Santa Fe Springs,CA 90671 (562)941-2990• (714)526-844! 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 15::2. Building Permit Number Building Permit Number 17 001-00249 24 801-00246 18 B01-00244 25 801-00241 19 801-00255 44 801-00254 20 801-00248 45 801-00188 • 21 801-00253 46 801-00252 22 001-00242 47 801-00247 23 801-00251 48 B01-00197 Dear Building Official: Southwest inspection and Testing was retained by the Owner to provide special inspection and materials testing in the areas that war root by section 1701 of the Uniform Building Code,approved pmjcct drawings and specifications,this work was witnecaad by the following special inspectors. Concrete plant was observed arra compressive strength samples were cast by,Pat Osterman(ICBG#106152581),Roy Lyndsay(ICI #503699849). Compressive strength samples were picked up by Southwest and tested in our laboratory.' All work was done in accordant with the project plans,specification and workmanship provisions of the Uniform Building Code. Stressing of',4"post tensioned tendons was observed by Roy Ward(OCEMA#0288).All work was done in accordance with the project plans,specifications and workmanship provisions of the Uniform Building Code. Based upon special inspection and materials testing wrinen reports of this work,it is our judgement that the inspected work was performc the best of our knowledge,in accordance with the approved plans,specifications and applicable wcxicmanship provision of the Uniform Building Code. S' 'ewedBy 74,A74-1±t.vN President r /7//1);_'S:.'-'"•• SLG n: • :k1g t t I tap. 3*-3!-cg / r• t4 Tuesday, November 20, 2001 2:23 PM Gary& Diana Shouse 702 396-5188 p.01 /‘t STRUCTURAL OBSERVATION GROUP GARY E.RUBIN 2249 AVALON STREET COSTA MESA, CALIFORNIA 92627 Pager. 9491227-8668 Billing: 7021396-7758 E-Fax: 1/8661732-6429 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 Group 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 worl®anship provisions of the Uniform Building Code, and in conformance with the Structural Engineers' recommendations, approved drawing's and/or revisions,project specifications and applicable workmanship provisions of the Uniform Building Code. ÷144-, Gary E. Rubin Structural Observation Group Owner GER/ds ' • CITY OF COSTA MESA t. 9@@ • BUILDING DIVISION F ',) DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER • PERMIT J to Mn1.nn19R (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 1638 BEECHWOOD Status: ISSUED Suite No Applied: 03/14/2001 Issued: 03/22/2001 Vicinity: PLAN 3 Parcel Number: TPN00065 - - - " ISSUED BY: �.� -a Applicant: PHILIPP, ROLANDj r!=: . j ; Address: 1565 W MAC ARTHUR _ '� -- ), ` ' ``_ /n i ' COSTA MESA,-CA\ ' \ 't Phone: l 714-668-43001' y C. �` G`/ V 2„„),,,_-,;-_--.2.:- I ', N'N �/ A .%;,„2.1:><%;11-7-.5::---r-?-2ip_�92626 „A�-- Owner. O STANDARD PACIFIC-HOMES . , -N\ /A(/// ,.-_,--",-2.K.------;% v // //,'"); Address:' V1565 W MAARTHUR '�`\,\ '% �_ ///,1Y>i '`�.A� % A� / p , COSTA MESA;CA Phone: 714-668-4300 R Z/ (;%//z //1/ Zip:/P92626 \V✓ \ /Wnr )owDER : I ;J r ) "'Phone' -- i �� , i� 7 J /I ii `� ,;"."..-,-1:C.ph . Zip: _ �1 , / _. v� ./� ' A t , if,it l� j {� License: 0 /'' \� a�n�`` :� ., r Arch/Eng `!`i '''.4 - '-x\\/ i _ \ l, 1 } �.�i Address ! (� • ) EC Ut ) L. / i rll �r C�Phone r�7vir�1 r ice. STr \1 \�. c_)(�l�)���'4 1 .111_ X1/1 z p, 1 ,..e r(1 1 1l rt.1 \ SII 1 ',1\O� License. � J p j- r---' 1A :r, �,� �_ 1\�A 1t� i r OR TEOFPEACFIC'HO ES2 SF „I/ ,CONSTRUCT NEW SFR PLAN 3-,FOR.STANDARD PACIFIC HOMES`2972SF.LIVING,579SF -'� GARAGE,20SF COVERED ENTRY, 133SFPATIO.`--"--'2/ I ``,.....---\ �\ 2 FAT<100K BTU, 1 FACTORY FIREPLACE, 1 HOOD W/MECH EXHAUST, 1 VENT FAN/SINGLE `DUCT,2 COMPRESSORS UP TO 3HP/100K BTU. R_EF: B01,00251:- \;._;,,,,\\..,--2 \,�v \ il FEE,SUMMARY I 12/ L `7/ AM �, I Quantity .r. ytt.,'?.:,j .. . ca.• , / \/ Pit^+.:-:+- Quantity ISSUE FEE $23.50 -'''':0„.,A,' , rr. ,Do°p Repaii/Alt-Absorbtion Unit J *$0.00/000/ Inst FAU<100 k BTU t/" '$29.60.4.2.-,,IL-t4 ;„ o !t- o3,Repair/Alt RefrigerratirinLUniti $0.00 0 Inst FAU>10'0 k,BTT $0:00 -0 .-.% _ O° q � p0 Ventillation S stem " � " " // ' c°>o` O-„ .• Y $0:00 0 Repair/Alt Cooling/Heat f $0.00�0 0 0 Eva oratiyeCooler 2N �, poo �'' o co o P ., ' $6.00 0 Inst/Rep. RecesslNalLHtr $0.000C, �� p ^o d Commercial Incinerator $0.00 0 Refrig Sys<100 k BTU \ `//'/S6:00 0`"----„,,___.''-"----„,„____ _0 c.©gy <Domestiic_Incinerator �"� 12$0.00 0 Refrig Sys>100 k BTU „3/4.\\., t C$0.00N 0 _____ , Compressors`?Absorption Systems Gas Piping \$OAO, 0 /� _Upto 3 hp/100.k.BTU \\c' �0 $29.40 2 Factory Fireplace $10.65J11 J/ ' 3 To_15,hp/:500 k BTU v $0.00 0 Hood w/Mech Exhaust X810.65 -11 l(^ C� 'j)--'I! -1 C---1-15-To 30,hp'/,1,060k BTU �� $0.00 0 VAV Box '-$0:00 0 c_j ,i - 30,To 50;h'p-('1\750 k BTU ,,J $0.00 0 Vent Fan/Single Duct $725-T),1--:--,--- \--- f l %��1v Over'50 hp/Over-1,750'BTU $0.00 0 Appliance $0.00 --0<c).„:,,,,,:-.:: _. Boilers-;,,, • Fire Dampers $0.00 0 ------_,___Th____"c --_,Up to. •h $0.00 0 Smoke Dampers $0.00 0 -3T6 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 rn ua1MMrS 'SDG^'N CQ'IDITI6t'S 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 / / 2446-46V (6/00) INI ( ) 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 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 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 0 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 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 and c. Bus' ss and Professions Code for this reason: I / O Signature: Date: Owner ID verified by driver's 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: I 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 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 0 N . (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 ❑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? 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? 0 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. 1 �Sig((aa re p'{f1L`L al er(s) 3 l� `l'�Da1te And/Or Authorized Applicant / / Dare CODE II INSPECTION MSPCTION TYK 1616 Fixed ystemEFinal Fire Prevention INTmAI$ 206 CODE* F nal Mechanical )1 a DPEEl 6 0l 1266 Pool Spa Final 208 Final Plumbing • 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy �� CITY OF COSTA MESA' q • BUILDING DIVISION :f,,•' Iii DEVELOPMENT SERVICES DEPARTMENT PER NUMBER t: ,- I PERMIT ta 'hwamrio r� P01-00143 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 1638 BEECHWOOD Status: ISSUED Suite No Applied: 03/15/2001 Issued: 03/22/2001 Vicinity: PLAN 3 Parcel Nunmber: TPN00065 ..- -" ,,, _ ISSUED BY: r l( I ti N.Applicant: PHILIPP, ROLAND N. Address: 1565 WMAC'ARTHUR(, I- , is ' V'=v' COSTA'MESA, CA\ --) ) Phone 714-668-4300�C / cam, v,; (% A / /- -.Zip _92626 \ V � /i Owner: STANDARD'PACIFIC HOMES '�� N. (/ / 11/ N. ' ////%,i ''-'-ON.i Address 1565 W,MACGARTHUR v ' 0//L' \:,vNAA� /7 COSTAMESA,CA Phone: 714-668-4300 ;v / /,''� Zip: 92826 N IA ' \ , r \ 11 ( e \ / / f� l 1 TO/OW 7' , . cam--: N r � ) ��Contractor OWNER-BUILDER � " J `� ( ( �J r rr / 1 -/ A r i /1 i Address r r/ I - !a 1�_ �------ -l'V � �, _ tri/f, , /7 -Al-- Phone: -2(1 V� )`� I O, / i ';0'I �-_- _--- -License: _0 : - -vc,.771 ����`\1 s---• t\! �'� Arlch / En�:�(I�r�I Lv'v' L A � 1- 1t :1L1:e -t-=-'S\t l- A..v -.) 1t�1 1`y (,1 \ tAddres :\\O\ i y -_ / / I f I L l 11' It= _ _ l'a\ / 1J ! d 1 1 t\ ,0 .lam.R _ - C (3_ ,,,///1(c- /1 ( Ce-21 �c ��� I License. '] i 1 \\\Iii t SCOPE OF PERMIT==� I `;R CONSTRUCT NEW SER-PLAN 3-FOR STANDARD PACIFIC HOMES:2972SF LIVING, 579S// V �- JGARAGE,20SF COVERED ENTRY, 133S,F,,;PATIOf3BATHRUBS, 1 DISHWASHER;1 EXPANSION TANK, D ` �_\ �--- 1 GAS:(1.4,OUTLETS),2 GAS OUTLETS,.(OVER4), 1`LAUNDRY TUB/WASHER, 1 PRESSURE \� REGULATOR, 1 SEWER CONNECT1'1(SHOWER, 1MITCHEN SINK,.,1 SERVICE/MOP SINK,r1 WASH) /f(�� <BASIN,2 WASH BASIN SETS;3 WATER CLOSETS,---1 WEER HEATER?1:WATER-SERVICE. `'Vy V Q 'REF: B001-002511'a= sy�'`'yt .b ,>"�-0,--0 G, C1�",. 'nry t" ,,� / /, 0 v ' " 8 FEESUMNIARY ° v� AMT OTY ..`\�-- AMT OTY ,(J / AMT QTY ISSUE FEE $23.50 �� LaundryTuti/Washer- $9.809 1\Sump Pump,90, $0.00 , 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00___-,0� SwimmingPool' $0.00 0 Backflow Preventer $0:000 strip _ ,,f\ r , p e 1(� $0.00 u6411127'r� $0.00 0 Bathtub $29.403` Pressure Regulator- l�$9.80 --2.; /Uiinal/ $0.00 0 Clarifier System $0.00 0`t Process Pipirig'(per.0 ft)--,,)6.60C-6 /f Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Sode,etc) $0.00 0.'------., ---'`-Receptors_ $0.00_-0.'x-,-O% .Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic TankaT5 -a�$OA02/%70/ Wash Basin $9.80 1 Dishwasher $9.80 1 Sewir Cap for-Demo $0:000 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 $12.30 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 �r(-rcen1n sLSand Auto l So nn n NOTICE: The work authorized by this permit shall comply with all applicable handicap access rei6MAteQA45UbAniikF6684a$286.44d related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically exjCOMMFN,T$JrSPECIAL rGCM/HiMBONSithin 180 days,or if work is suspended or abandoned fora 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 / 2 2446-46(6/001 C. DECLARATIONS { 3 WORKERS'COMPENSATION DECLARATION: • I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. My workers'compensation Insurance carrier and policy number are: Carrier: - Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit Is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia,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 DCA I ARE($100000),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# Contractors 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: I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions ode:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under �us,i,n�essgO1 d Professions Code for this reason: Signature: V Date: Z' Owner ID verified by driver's license. 0 Yes 0 No�J. 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? 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? ❑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 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 ❑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 0 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 AUTHORIZATON.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. `igna r"Of Lrta jrw ) '/ L/\ 2) -5/pat And/Or AuthoredApplicant Datil ;ODE# INSPECTION TYPE DATE' INTITIALE CODE# INSPECTION TYPE LATE MTRIALE 1616 Fixed System Final Fire Prevention 206 Final Mechanical zY 1266 Pool Spa Final 208 Final Plumbing i i -01ro` O( Saw 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 :Ir., CITY OF COSTA MESA BUILDING DIVISION :j(41•11111,1111 ,I c DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER . 1 ......-. appir4 i .J PERMIT �; E01-00198 man (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 1638 BEECHWOOD Status: ISSUED Suite No Applied: 03/14/2001 • Vicinity: PLAN 3 Issued: 03/22/2001 Parcel Nunmber: TPN00065 Applicant: PHILIPP, ROLAND - - N_ -- - ISSUED BY: -C Address: 1565 W MAC ART--H-'''U/R/--/;. 1c -' - --�.:\-C-- `- COSTA MESA(p -:- ,_ , Phone f 714-668-4300 i .` = /At; r" I Zip: • 92826 ft ,. �_ Owner: (STANDARD-PACIFIC-HOMES 'c' ` .,, v� A`� / . ' Address70/56 W MAC'ARTH R\ \ `�-'�� // /'�\� �` COSTA MESA,:w„-- Phone: 714-6684300 ��Vv\� .(1) " (f//7//� `--/%� Zip: 92626 A V�V�\/ lr•� / iii �� l/ Contractor. reOW,NER-BUILDER (• � ��-�\� Address) ,I. - • 1 / , ! 1�/ - r/ 17--h-‘91n!.:, ,,- / „,�i 1 1; l�% ii F o,4 m,e2�9 zip:- - -_ -,i /ti• � A. �- . rr '� /, I 2/1,±W- License: 0 ?'(/ \��)I '-1' ----.( 1� / i1I�� l C10\ 1 ! V lfJ0L--I % Ir1C ;7�-,%v SCOPEOF`PERMIT ,< (%�`FT v�N, 'ci0pi (� I i L H ,I R CONSTRUCT NEW SFR-PLAN:3-FOR STANDARD PACIFIC'HOMES:29.72SF LIVING,579SF )9,�I L ) I `; \ GARAGE,20SF COVERED'ENTRY, 133SEPATIO. - - -- --, Iu \1 1/1 NEW RES(1 UNIT) 2 LIFHT FIXTURES 3 OUTLETS 2 SWITCHES'1 MOTOR TO 1 HP.REF: x I �� (�\ uBOt-00251 �I 1y-,� �.-� ' - �'-.,' .i • '� lt, (.__:„*Th ._ / A rl \\ C ) \tin i FEE SUMMARY, // `h L� Vast <�,y --Quantity Jwa��:• �'I Quantit� ISSUE FEE \\ \ \ $23.50 ITemp D-ist SystemTLighting $0.00 0/ Temp service test\ ' $0.00 ,.,, .Busway/100 ft $0.00 f0 Q1 Res a/c packaged \\\i$0 00 ...;;C/c-7,4;,, Standing Section $0.00 0 New Res•(1 2 units) `$166.43 : 2972 4 X12-(- rr -Misc Electrical Equipment $0.00,. �o New Res(3+units) �'�� \$0,00 0 r ' "7 Transformers up to:1 kva/kw _ $0,00*'0 ice, Pool/Spa �f.1 $0;00 -0 . f' �0 +,-� ° up to=10 kva/kw:�t $0,00 G-f' Lighting Fixts $2.20 <20-,-1 p n >J v r` up to¢0 kvalk'w $0.00 N0 /q� Recept Outlets% $3.303 - 0 0 © a c--,‘, `� up to'100 kva/kw $$0.00 �J'/,0 J Switches \S CCC//F $2.20_, 2 creo erg:,\.' p °° - over 100 kva/kw-� $0.003 v 0/ O Non Res A I \ C$0.00 \�.. t! ° pp 0 '��` Lowyoltage Equipmerit $0.00 0 Q Res Appl % $0.00 // 0 ��= Cow-Volt:Wiring:System/Ckt C$0:00 Om', Service to 200a v$0.00 0 o -\ -- -_.Mise"Conduct \\ /$0.00 GO Service to 1000a :$0.00 O--j'T Misc.Conductor�c U $0.00 & 0 Service over 1000a $0-.00,`,...„... �OU `'' r/\ r�Circus('gen or`ride) $0100/o Motors to 1 hp $4175-- --,--_----„„1 I__) : Circus(Tech• ride:or lightss) , $0.00 0 Motors to 10hp $0.00 ��c0,\_., "'--' ! 1\Christmas Tree`Stand-_�f $0.00 0 Motors to 50hp $0.00 0*'c;,�,-,-___ - -Fireworks Stand��&//$0.00 0 Motors to 100hp $0.00 0 '�-'CcOther.Electiical;Fee- $0.00 Motors over 100hp $0.00 0 "_f- 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 7 2446-46(6/00) l / DECLARATIONS ;r ,t 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 ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES 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.N Class N 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 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 exemptars Business and Professions Code for this reason: Signature: Date: 3/t_! 6 Owner ID verified by driver's license. 0 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 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? 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 apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0No (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. .--� ^Sig re Ot Ifpggl er(s) t I�)1 01 Date And/Or Authorized Applican / Date CODE I INSPECTION TYPE PATE' . _ INnTIALS CODE k INSPECTION TYPE DATE INTInALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical ,a 1266 Pool Spa Final 208 Final Plumbing /%/li /� 200 Final Re-Roof 210 Final Electrical /1-15-19/ ''C/sA/"/`_ 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