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Home My WebLink About1067 CHEYENNE ST - Building Permits(714) 754-5273 • Fax (714) 764-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT Job Address: 1067 CHEYENNE ST Suite: Vicinity: Parcel Number: 14159520 Applicant: DUCHENE, DOUG Address: 7432 TALBERTAV. HUNTINGTON BCH. C.A. Owner: GOBSTER, PATRICIA A Address 1067 CHEYENNE ST COSTA MESA, CA . Contractor: DOUGLES HOMES Address: 7432 TALBERTAV. Arch : Address: Zip: HUNTINGTON BCH. C.A. Zip: 92648 Phone: License: BUILDING PERMIT Zoning: R1 R1 Phone: 842-5899 Zip: 92648 Phone: Zip: 92626 Phone. 842-5899 License: 542604 Eng Address PERMIT NUMBER ✓I B99-01743 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 10/28/1999 Issued: 10/28/1999 ISSUED BY:� Phone: License: SCOPE OF PERMIT REPAIRS AS PER HUD. REPLACE EXTERIOR DOORS AND PATIO DOOR. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $1,000.00 Permit: $38.75 Claim Valuation: $1,000.00 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $39.25 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 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 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. 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: S T"V 1� Policy Number: -3 CID (This section need not be camel ted i! the permit is valued atone hundred dollars ($100) or less.) ❑ 1 certify that in the pertor nce 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' n laws of alit 'a, it that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith triply with t eye provi ns. - tWARINING: Signatu Date: i0��iF3 —9g F RE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT ANE LOVER RIMINYC AL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED 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 CON CLARATION: I hereby a ' am Iicens d rider provisl ns aC abler 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force effect. Lic. # Cis I'J Co r for's Signature: CON UCTION 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: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 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? ❑Ves ❑ 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? E] Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? � Yes LJ 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). ___....-_......-tutu--._ --... 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 O 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 t 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 party for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner( lm-zg -9 i pDate uthor' d nt Da CODE Y. INSPECTION TYPE 1fATTE IWITALS CODEI INSPECTION TYPE pqi IN RA 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 Sign 222 Final Site 204 Final Demolition 250 Final Buili ing/Occupancy 2446-06 CITY OF COSTA MESA BUILDIMG DIVISION DEVELOPMENT SERVICES DEPARTMENT J PERMIT .mao (714) 754-5273 • Fax (714) 754-4856 Job Address Suite No Vicinity Parcel Nunmber Applicant Address Owner: Address Contractor: Address: 1067 CHEYENNE ST 14159520 DUCHENE, DOUG 7432 TALBERTAV. HUNTINGTON BCH. C.A. GOBSTER, PATRICIA A 1067 CHEYENNE ST COSTA MESA, CA DOUGLES HOMES 7432 TALBERTAV. HUNTINGTON BCH. C.A. REPAIRS AS PER HUD 2 SWITCHES AND 1 MOTOR FOR EXHAUST FAN. ELECTRICAL PERMIT Phone: 842-5899 Zip: 92648 Phone: Zip: 92626 Phone: 842-5899 Zip: 92648 License: 542604 PERMIT NUMBER E99-01017 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 10/28/1999 Issued: 10/28/1999 ISSUED _ =f • SCOPE OF PERMIT REPLACE EXTERIOR DOORS AND PATIO DOOR. 10 LIGHTS, 5 OUTLETS AND Quantity . ISSUE FEE $23.50 0 Temp service test $0.00 0 Res. a/c package $0.00 0 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool / Spa $0.00 0 Lighting Fixts $11.00 10 Recept Outlets $5.50 5 Switches $2.20 2 Non Res Appl $0.00 0 Res Appl $0.00 0 Service to 200a $0.00 0 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to 1 hp $4.75 1 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 1 00h $0.00 0 Motors over 100hp $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 FEE SUMMARY Quantity Temp Dist System / Lighting $0.00 0 Busway /100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kva/kw $0.00 0 ................ up to 10 kva/kw $0.00 0 ................. up to 50 kva/kw $0.00 0 ................. up to 100 kva/kw $0.00 0 ..................over 100 kva/kw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Misc. Conduit $0.00 0 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (mech ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee $0.00 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $46.95 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 Ink 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: t Policy Number: OID2376-00 (This section need not be ompleled it the permit Is valued atone hundred dollars ($100) or less.) ❑ 1 certify that in he p ormanc Ltha-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 sof his, and agree t if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these ns. Applicant Signature: Date: _ 10--Z45'91 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(StOQ0001, IN ADDITION TO THE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION V060F THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DEATION: I hereby affirm that I am licens unB[ovi ns osfti f Chia (commencing with Section 7000) of Division 3 of the Busin�7and Professions Code, and my license is in full force and effect. Lic. # Class # Contractors Signature: Date: .10-Z�i'1q 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: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than 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 Cade 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)? ❑ Vas ❑ 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? [3 Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a8P rmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? � Yes LJ 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? ❑Ves ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 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 (It "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 slate 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 c6T 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 prop or inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Of Legal Owner Date A Or Date CODE it INSPECTION TYPE DATE INTRIALS CODE N INSPECTION TYPE 1j AST INTI 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical `f 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 2446-46 L 51p M CITY OF COSTA MESA ,4 _ BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT ERMIT NUMBER 'q.�� PERMIT M99-00494 (714) 754-5273 • Fax(714)754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 1067 CHEYENNE ST Status: ISSUED Suite No Applied: 10/28/1999 Issued: 10/28/1999 Vicinity: Parcel Number: 14159520 ISSUED BY: - L-fto Applicant: DUCHENE, DOUG Address: 7432 TALBERTAV. Phone: 842-5899 HUNTINGTON BCH. C.A. Zip: 92648 Owner: GOBSTER, PATRICIA A Address: 1057 CHEYENNE ST 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 Phone: COSTA MESA, CA Zip: 92626 Contractor: DOUGLES HOMES Address: 7432 TALBERTAV. Phone: 842-5899 HUNTINGTON BCH. C.A. Zip: 92648 License: 542604 Arch/Eng: Address: Phone: Zip: License: SCOPE OF PERMIT REPAIRS AS PER HUD. EXHAUST KITCHEN FAN. REF B99-01743. FEE SUMMARY Quantity Quantity ISSUE FEE $22.00 Repair/ Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair / Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst / Rep. Recess Wall His $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys <I00 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys >100 k BTU $0.00 0 Compressors /Absorption Systems Gas Piping $0.00 0 Up to 3 hp/100k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp/500k BTU $0.00 0 Hood w/Meth Exhaust $0.00 0 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp 11,750 k BTU $0.00 0 Vent Fan / Single Duct $6.50 1 Over 50 hp / Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $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 $28.50 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 All WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section'3700 of the Labor Code, for the performance Of the work for which this permit is issued. I have 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: >/ q Carder. ON1 Policy Number: 17 `02-3 7(o - co (This section need not be mpleted it the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in.2e p ormance 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 thsof alit that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with the i s. Applicant Signature: Date: ./0'2R" 191 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 ($100,0001, IN Al JDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTOR DE \ ATION: I hereby affirm that I am lican u r provi (commencing with Section 7000) of Division 3 of the Bus and Professions Code, and my license is in full force and effect. Lic. # I Class # Contractor's Signature: Date: /O-'Ze CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lander'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).): ❑ 1, 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. It, 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.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 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 orrwill willthe 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? ❑Ves -_ONO ... _._........ ............. 5 Does or will the applicant present or future building occupant require for the work which is the .___— subject this a plication appermit for such construction or modification from the South Coast Air Quality ality Management District or from any other air pollution control district or agency? y? Yes LJ 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 pan 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 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 regard i g Hazardous Materials and Emissions. Signet e: Date: CERTIFICAted 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 acomply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abo a-descop o ec Io es. I agree not to occupy or allow occupancy of any building authorized by this permit unfit final inspection. Signature Of Legal O ner(s) Date An Applicant /LLQ g9 Date CODE J. INSPECTION TYPE MR I TI -y TIgLS CODE I INSPECTION TYPE DATE 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 Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 24x6-06 I Orivers'll..I&hseyrr SS CMF 0865-46, rev. 10/84 CSNo Date Reinspection Fee $15 Building; Canary- Applicant; Pink - Accounting; Goldenrod. Assessor MECHANICAL $ TOTAL FEE : $ 20 -SO I Issue Fee $ 3 PLAN CHECK 25% ; $ ' i ' (\\ _ Applicant to fill in all spaces except those within heavy border fines and sign all appropriate declarations. ax ax CITY OF COSTA MESA . CONSTRUCTION PERMIT PER6NU. 1RACTNO.' LOT NO. _ UNIT NO. ,a 8391 ?/28/'85 c0e50 Tl. ' 6 % �iliC G.Ii.v< - _ '`/ - 1777 ,� ,. S F /�;. `. ! Project Address —i . 1 1 Applicant's Mailing Address� 4yC7S4 -. et✓a+G2s✓e'C•0. ip f, TYPE OF CONSTRUCTION, 0 NEW ADD: ALTERATION 'LTREPAIR - �e1 Owners Name PA/RiGra -i CONSTRUCTION AND PLANNING _POOL & SPA APPROVALS Permit # ' ?Date - I nspector - - : APPROVALS Permit # _ Date inspecrnr' - -. 1.. Temporary Electrical Service.or Pole - . 52.- Pool& Equipment Location - '.'2^ Soil Pipe-Undrgrnd: 53:. Steel?Reinforcement 3. Electrical Conduit Utility-Undrgrnd. •- - - 54. Forms -• - ,4. Electrical Conduit-Undrgrnd: -' i 55: Electrical`Bonding 5. Steel Reinforcement - ' ' - 56. Rough -Plumbing & Pressure Test 6..'Electrical UFER Grnd. ,� - - 57. APPROVAL TO COVER-GUNITE= .7. 'Footings - `. 58:: Electrical. Conduit-Undrgrnd. ',8. Foundation - -' - 56. -,Gas, Pipe, O Undrgrnd., Test - 9. Water PipeEUndrgrnd. - - - -� 60. A Backwash Lines, P -Trap, O Undrgrnd. 10. Structural Floor Syst6m ', 61 ."APPROVAL TO DECK .11. Property Sewer Line & House Connection _ 62. Backwash& Receptor -Final ' 1 12. Sewer Cap ' 63. Heater & Vent -Final 13. Roof Drains - = 64. PlumbingrSystem - Final - •' _ ' - - . 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit - - - - - ' - - ""- `66. Solar System -Final- , 16.1''Rough Electric Wiring -` -67"Fencirfig & Access Approval - --�- - , 17. Rough Wiring Sign _ 681 APPROVED FOR PLASTERING - c 18. Rough Elec4rical=T,Bar Ceiling `. 69t POOL%SPA SYSTEMS FINAL - 19.. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit# ' 20. Rough Factory Fireplace 21 .;Ducts, in Structure - - 70. Underground Hydro _ -22. Ducts-, Ventilating I 71. Product Piping O Gas ❑ Oil i 23. Gas -Pipe -Rough & Test 72, Underground Flush �24. Roof Framing 73, Undergrnd.Sto�ageTank ❑ 1. Gas OOilr - 25. Roof Sheathing _ �;� , ; f_ .: ._ '74. OverheadHydro 26.IT-Bar Ceili6(Structural) & Monocoat I 9 �. ' 75. Dry Chemical _ - 27. 'Frame and Flashing 76: Dry Standpipe 28. Lathing & Sidings ; 77. FIXED SYSTEM FINAL 29. Insulation ,78. FIRE PREV. FINAL - 30'. Drywall Nailing - - ' 'HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat r• 79. FINAL INSPECTION 32. *Electrical Power Meter -Final 180.. FOOD CERTIFICATE ISSUED 33. Final Electric .' ! - ' ' 'Notes'' 400 r. 41 34. Final Heating & Air Conditioning I 35. Final Gas,Pipe-Test -,v •- _ , 36. Hood or.CanopY 37. Final Factory Fireplace - - i, n 38. Final Plumbing --- 39. Water Service -Final - 40. Gas Service -Final � m - 41. Solar Domestic -Final 42. BackflowPreventers -, I 43. Backflow' Irrigation - - 44. ,Landscape Irrigation System 4j,- 45. Sound AttenuationI1 -- - ' 46. Handicap'Regulations _ I 47. FINAL STRUCTURE & BUILDING _ 48. Special Requirements Completed I -- I ,8 49. Electric Release to Edison - - ' -.+ 4" - i --, t .• t 50. Gas Release to Southern California Gas Co 51. CERTIFICATE.OF,000UPANCY, No. - ` Date ,� l I I .• ROO. ;OVERING CERTIFIC ,'ION j , Permit No. tg 1 77/�� Property address 10i-7 C' -4 -e e e- -V aCoJ%•o xie r a (5-A 2L6 Z, - Owner Fk7A, e r'.r �¢• �io (>1 Te f. Contractor Cdo " 9 Sjire/+//'ty State Contractor License Number 3G 2.3 9 r Classification G � 3 I hereby certify that I have installed, or caused to be installed, a minimum Class C roof covering at the above address in conformance with Chapter 32, and Section 1704 of the 1979 Uniform Building Code, as amended in Section 5-17 Title 5 Costa Mesa Municipal Code, and the installation instructions of the manufacturer. ❑ I further certify that I am the owner of the property. (Owner -Builder permittee only). ❑ 1 further certify that I am: ❑ Owner of sole proprietorship company 2C Full partner of the company ❑ Limited partner of the company ❑ Officer of the corporation I certify that as an authorized officer or agent of the company or corporation, I am empowered to make this certification, which shall be binding on all successors or assigns of the company or corporation. I shall deliver a copy of this Certification to the above listed owner, after submittal of form to the Building Division for acceptance. Received by Building Division by: I e7 3 IyITz- InitiaDate Space for Notarial Statement for authorized officer or agent actor; k�.� 'SCG/g/T C mpany or Corporate Name 7%.5? %7k2/SN. Address . Jt�r ��ai �• G'N�jd/C2 l`Q Printed or Typed Name 18708 COSTA MESA BUILDING -SAFETY DEPARTMENT P. O. BOX 817 COSTA MESA. CALIFORNIA For Applicant to Fill In Completely TYPE OR PRINT E BUILDING COSTA MESA. CALIFORNIA TEL. SIZE I NO. OF BLDGS. OF LOT NOW ON LOT USE OF EXISTING BLDG. SETBACK LINE FROM �• �� DESCRIPTION OF WORK 'BZE DING 52 x 49'NO. OF 16 SROOMS EXTERIOR WAIL- 7 ROOF in HEIVED VFEB 1 9 1963 . FINANCE DEPT. APPLICATION11 UF FOR -PhERMITA BUILDING For Office Use Only RECEIVED BY P.tY3 RECFIVIE DATE ISSUED � GR;3 BUILDING ADDRESS /OIIOO/ / 7 COSTA MESA. C IFORNIA I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUCTION. SIGNATURE OF PERMITTE AUTHORIZED AGE 1L/li��S ?b LIC THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. VALUATION PERMIT FEE $ PLAN CHECK $ z O u ZONING ZONE NO. OF �j USE OF NEW sem% Al, / ��I PLANE (� BUILDING lV/q 9w LEGAL DESCRIPTION A. P. NO. YARDS EVES APPROVED ALLOWED O (CENTER LINE ST.) FRONT 5 FT. IN. �— R. SIDE FT. IN L. SIDE FT. IN REAR FT. IN — BYPRDVED ATF�-I`t-6< I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUCTION. SIGNATURE OF PERMITTE AUTHORIZED AGE 1L/li��S ?b LIC THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. VALUATION PERMIT FEE $ PLAN CHECK $ z O u