HomeMy WebLinkAbout1035 CONCORD ST - Building Permits4 CITY OF COSTA MESA
BUILDING DIVISION
i 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
s� FOR INSPECTIONS CALL: (714) 754-5626
"FesM'r
PERMIT NUMBER
PERMIT TYPE
ELEC STATUS:
APN: 14165218
DATE ISSUED:
ISSUED BY:
JOB ADDRESS:
1035 CONCORD ST CM Suite/Unit:,, us'
Vicinity:
r . . _
! _
SCOPE OF WORK:
CHANGE -OUT ELEC SERVICE AT AN EXISTING SFD. NO OTHER WORK AUTHOF
. .-`,%,AF 4.'1
FINALED
11105/2007
BJK
S r v .'r+�� ,
y.
OWNER: WINGERT, JUNETTE A TR i; (.,r Address 1035CONCORD)ST} Unit:
PHONE:
APPLICANT: C STANLEY WINGERT
PHONE: 714-546-8557
Address K Umt
City/State.'/f'� t4l
mit Fee:
Fee
TOT
LDER j
f ;PHONE:
r n 7 r
t.
FEES
:. $0.00
$54.00"1
$0.00r
�i$54.00.-.^
F-�
l:.
WITH THIS. PERMIT.
5`CONCORD ST Unit:
STA MESA, CA .i
se'No. 000000 . _. .
CELL: ,
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
G94E-6_`. '`�` 1_ ,I Q&R '11MRA�3 Wd �Itl TT_ 4.._ � � ''•PST& !NMUL
1818' i Fined System Final Fila Prevention S' - a 206 Final Meehanioal -If
'
0_12156"Pool Spa Finals 208 FinalPlumbing,- -?
200- 'Final Re -Root 210 Final Elednwl""'O` bSF 7.0}�
201--- Final Block/Retaining Wall
i 212 Final Fire Prevention -
_ _ -.. } _ r - - -
202 'Final Factory Fire Place - 220 Final Planning Approval-
. 203- ,'Finnal&ign -e.t t 'l' �' 222 Final Site
204 Final Demolition -,- 250. ; Final Building/Occupancy
Fr '
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the ing 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 (or which this permit is issued.
❑ 1 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:
(Tho; section new not be Nmplefetl d Ibe penM is valued of one hundred doNars (S100) a leu )
Policy Number:
❑ 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.
ApoliQnt's 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 DOLLARS
(5700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and
my license is in full force and effect.
Lic. # Class #
Contractor's Signature Date
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
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 Cede: 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 contraclods) license pursuant to the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
Date
Owner ID verified by drive. nse. ❑ 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) feel 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.
Apph[anrs Signature
Division of Industrial Safety Permit Number:
Dale
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to file and
certify a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some
exceptions, that a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard temperature and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
hazardous materials equal to or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
temperature and pressure).
3. Does or will the applicant or present or future building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the
Costa Mesa Fire Department may require the preparation, certification and
fling with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
4. If an RMPP is presently required, has Section 25534 of the California
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require for
the work which is the subject of this application a permit for such construction
or modification from the South Coast Air Quality Management District or from
any other air pollution control district or agency? ❑ Yes ❑ No
(Section 65850.2 of the California Government Code requires that the requested
information be fumished on applications for non-residential building permits).
6. Will any part of the facility to be constructed under this permit be within
1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If "yes", the facility must meet the requirement of Sections 25534 and 42303
of the California Health and Safety Code).
7. If a permit from the South Coast Air Quality Management District or other
air pollution control district or agency is required for the work which is the
subject of this application, have all of the disclosures prescribed by California
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No,
6. (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 stale laws and
city ordinances regarding Hazardous Materials and Emissions.
Sgnawre Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 1
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 stale laws and city
ordinances relating to building construction, and authorize representatives of
the City of Costa Mesa to enter upon the above-described property for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
Signature of Legal Ovmegs) Date
3057 4 6 (310 7) Andlor Autnonied APphrant Date
Requested Inspect Date: Frida Ma 1f�I�T NUMBER: E07-00888
Site Address: 1035 CONCs
0 D
A/PID Information
PERTis 'tT�� E071@eW8 Type: ELEC
Occupancy:
APN:Co�ffawc dl 1QWNER BUILDER E A TR
Applicant: C STANLEY WINGERT
Description: CHANGE -OUT ELEC SERVICE AT AN E
PERMIT.
J013 ADMESSYIAY gE3&CVKG W S1AE0AffTER;
Sub TRUTIMP FINALE atus: FINALED
DATE&�rU�ED: 11110ftea:
PJK
XISTING SFD. NO OTHER4WORK AUTHORIZED WITH THIS
PROP OWNEa1►WIt&#CK WITH EDISON. - KUBOT BJ
Vicinity:
Requested Inspect�io,ynq(sy)�;�p1TELEG�g�
SCOPE OF WR§A; "lrO FIpTA(HLEEGTRICALCE AT AN EXISTING SFD. NO OTHER
WORK
AUTHTimeORIZED
O IITTH THIS PERMIT.
RequeRequestor: Phone:
Assigned To: """""" Entered By: TEMPEMP K
Action: Time Exp:
Cornen
OWNER: WIN ERT, JUNETTE A TR Address: 1035 CONCORD ST Unit:
PHONE: City/State/Zip: COSTA MESA, CA
APPLICANT: C STANLEY WINGERT
Potion "1 { -8557
commem:
Address: 1035 CONCORD ST Unit
City/State/zZip: COSTA MESA, CA
License No. 000000
CELL:
Approved "
Action: AP APPROVED
Action: AP APPROVED
REPT131 Run Id: 9020
i
CITY OF COSTA MESA
BUILDING DIVISION
77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER: BX08-00088
B MISC STATUS: ISSUED
DATE ISSUED: 03/3112008
ISSUED BY: RMD
PERMIT TYPE
APN: 42243209
Zoning: r
JOB ADDRESS: 853 CONGRESS ST CM,
Suite/Unit:
Vicinity: EXTERIOR OF HOUSE -
Primary Occ: Const Type :??
SQ. FT: 0 - '
Valuation: $4,000.00 -
SCOPE OF WORK:
-
REPAIR DRYWROUGHT FACIA; REPLACE STUCCO.
AT FACIA, AND REPLACE 2 DOORS; LIKE;FOR LIKE FOR A SFD.
OWNER: PRICE, JANE HSR ' -- -
Address:: 853 CONGRESS ST Unit
City/State: COSTA MESA; SCA.-:
Zip Code: "92627-3337,`;
Phone:
Final Electrical
201
Final Block/Retaining WQI
212
Final Fire Prevention
APPLICANT: PRADO, SOFIA --
.. Address: ,. 915 LAKE STREET - Unit:
City/State: HUNTINGTON BEACH„CA -
Zip Code: 92648
Phone: 714-960-705.2
I C
Final Sign
CONTRACTOR: J K.CONSTRUCTION -
License No:` 450297,'
Address: 915 LAKE ST i
- Unit:
City/State: HUNTINGTON BEACH, CA
-
Zip Code: 92648
Phone. 714-404-9846 CELL 'Cell: 714-960-7052
ARCHITECT: _
- - - License No. .
_
Phone
ENGINEER: . -
License No. --
Phone
;IX4&1tlh1 hr IAffi
Building Plan Check:
$0.00
Building Permit:.
$97.25 .:-
Electrical Permit' ,
$0.00 - -
SMIP Residential
$0.50
SMIP Commercial -
. - $0.00 - • -
TOTAL FEES -
$97.75 -
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE #.
INSPECT10N TYPE DATE INTMALS
CODE#
INSPECTION TYPE
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 WQI
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
DATE INIRIALS
W ATION DECLARATION:
I hereby 'TWUM r, enalty 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 i5 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' com ensation nsurance carrier and policy
number are: I _ 71
Carrier: l
(This seribnne txx0(CX ( %'� %e/1e"��delhe'pamrt iss�v Iued of me hundmdtldlars($100)o less)
Policy Number: ( Y, �a `.7
❑ 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 37!0/0 of
the Labor C h I f r,ry,i compyy th these provisio7 //h y
ppli nl&gnature �//l�
73 //0
V CI
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 DOLLARS
($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.
Lk. # Class #
r o s a ure _Dat
CONSTIR TION L NDING 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:
Date
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5,
Business and Professions Code: Any city or county which requires a permit to
construct. alter, improve, demolish, or repair any structure, prior to its
issuance, also requires the applicant for such permit to file a signed statement
that he or she is licensed pursuant to the provisions of the Contractors
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole
compensation, WILL DO THE WORK, and the structure is not intended or
offered for sale (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an owner of property who builds or improves
thereon, and who does such work himself or herself or through his or her own
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of
completion, the owner -builder will have the burden of proving that he or she
did not build or improve for purpose of sale.).
❑ 1, as owner of the property. am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and
Professions Code: The contractors License Law does not appy to an caner 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:
Owner ID verified by driver's licer.
Driver's License No.
J Yes ❑ No i )
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, a demolition
or dismantling thereof, will be more than thirty-six (36) feel 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.
App4pant's Signature Date
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to file and
certify a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some
exceptions, that a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
500 pounds. or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard temperature and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
hazardous materials equal to or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
temperature and pressure).
3. Does or will the applicant or present or future building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the
Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
4. If an RMPP is presently required. has Section 25534 of the California
Health and Safety Code been fully complied with? ❑ Yes ❑ No
S. Does or will the applicant or present or future building occupant require for
the work which is the subject of this application a permit for such construction
or modification from the South Coast Air Quality Management District or from
any other air pollution control district or agency? ❑ Yes ❑ No
(Section 65850.2 of the California Government Code requires that the requested
information be furnished on applications for non-residential building permits).
6. Will any part of the facility to be constructed under this permit be within
1000 feet from the outer boundaries of a school? []Yes ❑ No
(If 'yes', the facility must meet the requirement of Sections 25534 and 42303
of the California Health and Safety Code).
7. If a permit from the South Coast Air Quality Management District or other
air pollution control district or agency is required for the work which is the
subject of this application, have all of the disclosures prescribed by California
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
8. (If 'yes", attach certificate of compliance from the appropriate air pollution
control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
information given above is correct. I agree to comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
We
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.
S ur I eget ers ItDaI ]
Segnawre Dale I/ Y
305]-46 (3IOT) r MthjrzeJVAPM.M G ate,
CITY OF COSTA MESA
F BUILDING DIVISION
>` 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
°omna.fi . FOR INSPECTIONS CALL: (714) 754.5626
PERMIT NUMBER!'E07-00888
PERMIT TYPE ELEC STATUS: ISSUED
DATEISSUED: 1110512007
ISSUED BY: BJK
JOB ADDRESS: 1035 CONCORD ST CM Suite/Unit:
Vicinity
a'
SCOPE OF WORK: CHANGE -OUT ELEC SERVICE AT AWEXISTING SFD. NO OTHER -WORK AUTHORIZED WITH THIS PERMIT
OWNER: WINGERT, JUNETTE A TR Address: 1035 CONCORD ST Unit:
PHONE: - - City/State/Zip: 'COSTA MESA; CA -
APPLICANT: C STANLEY. WINGERT'
PHONE: 714-546-8557 1
CONTRACTOR: OWNER -BUILDER
Address: Unit: ' PHONE: - -
City/State: ZipCode:
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $54.00
Reinspection Fee $0.00
TOTAL FEES $54.00
Address: 1035 CONCORD ST Unit:
City/State/zZip: COSTA MESA, CA '
License No. 000000
CELL:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE/. INSPECTION TYPE DATE INTRIALS CODE/ INSPECMON TYPE OATS INTIMAL
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
f
WORKERS' COMPENSATION DECLARATIOr*
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:
(This section neednof be mrnpleted d the perraf is milted at one hurnared dodars ($100) a less.)
Policy Number:
xI 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 subj ct to the workers' compensation provisions of Section 3700 of
the Labor tle, I shall forthwith comply with these provisions.
Applicant's Signature Date
W NTNG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
I UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and
my license is in full force and effect.
Lic. # Class #
Contractor's Signature
Date
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Address:
Signature - - Date
OWNER -BUILDER DECLARATIONS:
I hereby affinn 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).):
las 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.).
❑ lam exempt under sec.
Business and Professions Code for this reason:
�a?
Signature Date
30V6 (3V07)
( 1
Owner ID verified by dri e. Yes E] No
Driver's License No. Expires:Q
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, a 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.
Applicant's Signature
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 Safely Code requires, with some
exceptions, that a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard temperature and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code. with some
exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
hazardous materials equal to or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
temperature and pressure).
3. Does or will the applicant or present or future building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the
Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
4. If an RMPP is presently required, has Section 25534 of the California
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require for
the work which is the subject of this application a permit for such construction
or modification from the South Coast Air Quality Management District or from
any other air pollution control district or agency? ❑ Yes ❑ No
(Section 65850.2 of the California Government Code requires that the requested
information be furnished on applications for non-residential building permits).
6. Will any part of the facility to be constructed under this permit be within
1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(if 'yes", the facility must meet the requirement of Sections 25534 and 42303
of the California Health and Safety Code).
7. If a permit from the South Coast Air Quality Management District or other
air pollution control district or agency is required for the work which is the
subject of this application, have all of the disclosures prescribed by California
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
B. (if 'yes". attach certificate of compliance from the appropriate air pollution
control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
information given above is correct. I agree to Comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
Signature Date
CERTIFICATE OF COMPLIANCE AND 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
pu poses. I agree not to occupy or allow occupancy of any building
authorized this permit until final inspection.
Signature of Legal Owners) Da e
I And1cr Authorized Applicant Date
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
Y OF COSTA MES ON$�TRUCTION PERMIT
Project Adore - C� ICS /UGUYtQ
Appliczit's'Mailin Address �� �`� S�GNI "—
Owner's
Owner's Name
Address lel C4V1'&Q03^0
Arch/Eng. License No.
Address
Contractor's Name G�G -Oa /,►/e Ph �dy 110
Address (mailing) LIuH�V pL
City License No. 6��
LICENSED CONTRACTOR DECLARATION'
hereby affirm that I am licensed under, provisions of Charter 9 (commencing
th section 7000) of Division 3 of the Business and Professions Code, and
y license,is in ff I tory �d effect. p� C 2
1 License Class-( �-'i7 - Li nse No.- � 2��
Date fm'/ c'onar r �-0 ssA l7ip}s;g
( WORKERS' COMPENSATION DECLARATION
"13I 1 hereby affirm that I have a certificate of consent to self -Insure or a certificate
of Workers' Compensation Insurance, or a certified copy thereof (Section
3800, Lab. ) moi/
Poli N/-' efa sea 6 6 to CompanY� �/J V -D
Cer fed copy i5 hereby furnished.
Ce ifietl co9y s died with the city Bu' i9� Divi ion
D t ��—��+^�+� Applicant ��r1a-li
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(This section need not be completed if the permit is for one hundred ($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.
Data Signature
NOTICE: If, after making this declaration, you should become subject to the
Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
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 (Section 3097 Civ. C.)
Lender's Name
Lender's Address
OWNER BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Section 7031.5 Business and Professional 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/she Is licensed pursuant t0 the provisions of
the Contractor's License Law (Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code) or that he/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
Briefly 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 (Section 7044, Business and Professional Code: The Contractor's
License Law does not apply to an owner of a property who builds or improves
thereon, and who does such work himself/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 com-
pletion, the owner will have the burden of proving he/She did net build or im-
prove for the purpose of Sale).
D 1, as owner of the property, am exclusively contracting with licensed con-
tractors to construct the project (Section 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such projects with a con-
tractors) license pursuant to the Contractor's License Law). I am aware that
proof of their Worker's Compensation insurance should be provided t0 me.
❑ 1 am exempt under Section B. & P. C. for this reason
Date
or SS
CMF 0865-46, rev. 10/84
. Owner
have read this
that the above
mty ordinances
mthorize repre-
f/roperty for
.%-A- 96
rpnry rvu.^�
SCJ
in-vul rvtr.
wi rvu.
UNIT NO.
'
5225 10/15/86
26.50
TYPE OF CONSTRUCTION U NEW U ADD U ALTERATION kTREPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER
DES IPTION OF WORK/USE OFBLOG. /yS RLL 6445.5 14,
E/¢5 S S'/•{////F/p
A.P. #
Zone
S
Main Building: Accessory Building:
TYPE OF PERMIT U GRADING U FOUNDATION ❑ STRUCTURAL
❑ TENA E CTRI AL ❑ PLUMBING 1:1 MECHANICAL
�,"p
❑ OTHE r C9O' /�
T
Front
Z
0
B
A
Rear
N
I
G
Right
N
PROJECT DESCRIPTION SO. FT. 2 OCCUPANCY ,tt�
CONSTRUCTION TYPE VALUATION$4�
ZONE GRADING CU.YDS. ACRES
K
S
Left
_
G
R
Ping. Ref. # Parking Req./Provided
E
Q
Remarks:'
�
Planning Notes:
M
-
T
S
PLUMBING
FEES
Bar Sink
Showers
ELECTRICAL
FEES
Backflow Preventer
Service Sink
Automatic Washer
Construction Pole Sub.
Transformer D 15-50 KW
• ❑'50+KW
Backflow Irrigation Sewer Ca
9 P
Bathtubs
Sewer Connection
Cooking Unit
Meter Dup to 100 amps
Clarifiers
Solar Collectors
Dishwasher
Meter Dover 100 amps
Dishwasher
Solar Piping
Dryers ❑Gas ❑Electric
Sub Panel
Drinking Fountains
Solar Tank,
Fan
Motors 00-1 HP 01%:8.
Floor Drains
Swimming Pool w/Spa
F.A.U.
Inc. Solar 09-15 HP 016-15+
Floor Sinks
Urinal
Fixtures
Microwave
Gas Service Outlets
Water Closet
Device Boxes
Pale Light
Interceptors
-Water Heater
Outlets
Range
Kitchen Sink
Water Service
Switches
Sign
Lavatories
Auto -Wash
Garbage Disposal
Standing Sections
P -Trap
Laundry Trays
Generator 110-5 KW 05-15 KW
Trash Compactor
Roof Drains
Reinspection Fee
$15
Issue Fee
$ 3
Reinspection Fee
$15
Issue Fee
_
$ 3
MECHANICAL
FEES
DEVELOPMENT SERVICES REQUIREMENTS:
Zoning Approved By Date
Building Approved By Date
Application Issued By Date_J.S.(
1
Boiler
Hood or Type I ❑
Canopy Type I I El
Duct -Under Ground
Duct - Structural
Refrigeration System
❑0-100,000 BTU 0100,000BTU
Duct -Ventilating
BUILDING PERMIT
PLAN CHECK
PLUMBING
PLAN CHECK 25%
ELECTRICAL
PLAN CHECK 50%
MECHANICAL
PLAN CHECK 25%
SUMM/jf1V
$
$
$
$
$
$
$
$
b!UEES r�^
pity `(J �f SMIP $ (�
- PERMIT .
ISSUANCE $
ENERGY P.C. $
GRADING $
MICROFILM $
TOTAL FEE $ L
Exhaust System 0 Multiple 13
System Repair/Alteration
Firepl/Fact. elf. ICBG#
Fire Dampers
Heating System & Ducting
00.100,000 BTU 0100,0008T
Registers
Reinspection Fee
$15
Issue Fee
$ 3
Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor
CONSTRUCTION AND PLANNING
APPROVALS Permit #
Date
Inspector
POOL & SPA
APPROVALS Permit #
Date
Inspector
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.
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.
B. Foundation ,
59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-Undrgrnd.
60. Backwash Lines, P -Trap, 0 Undrgrnd.
10. Structural Floor System
61. APPROVAL TO DECK
11. Property Sewer Line & House Connection
62. Backwash & Receptor -Final
12. Sewer Cap
63. Heater & Vent -Final
13. Roof Drains
64. Plumbing System - Final
14. Rough Plumbing
65. Electrical -Final
15. Rough Electrical -Conduit
66. Solar System -Final '
16. Rough Electric Wiring
67. Fencing & Access Approval
17. Rough Wiring Sign
68. APPROVED FOR PLASTERING
18. Rough Electrical -T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning
FIRE DEPT. REQUIREMENT
APPROVALS Permit #
1
20. Rough Factory Fireplace
21. Ducts, in Structure
70. Underground Hydro
22. Ducts, Ventilating
71. Product Piping 0 Gas 0 Oil
23. Gas Pipe -Rough & Test
72. Underground Flush
24. Roof Framing
73. Undergrnd. Storage Tank []Gas 0Oil
25. Roof Sheathing
74. Overhead Hydro
26. T -Bar Ceiling (Structural) & Monocoat
75. Dry Chemical
27. Frame and Flashing
76. Dry Standpipe
28. Lathing & Siding
77. FIXED SYSTEM FINAL
29' Insulation
78. FIRE PREV. FINAL
30. Drywall Nailing
HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat
79. FINAL INSPECTION
32. Electrical Power Meter -Final
80. FOOD CERTIFICATE ISSUED
33. Final Electric
Notes: -:p
34. Final Heating & Air Conditioning
35. Final Gas Pipe -Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
'
39. Water Service -Final
40. Gas Service -Final
41. Solar Domestic -Final
'
42. Backflow Prevenfer
43: Backflow Irrigation
!44.• Landscape Irrigation System
.1 '
45. Sound Attenuation
�46. Handicap Regulations
47. FINAL, STRUCTURE & BUILDING
''
'
48. Special Requirements Completed
'
49. Electric Release to Edison
't
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
19934
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 317 COSTA MESA. CALIFORNIA
For Applicant to Fill In Completely
TYPE OR PRINT
BUILDING
ADDRESS Q C
COSTA MESA. CALIFORNIA
OWNER a
FoIt 1
M
SET.ACK LINE FROM n _ '1111
1 DESCRIPTION OF WORK ■
BUILDING
NO.
SIZE
ROOMS J
EXTERIOR WAL
ROOF
COVERING
I�COVERINGS ING S
USb FBLDINGAND
ORKT BEPERFO
R THIS
q C_ D A
APPI� TION
E/TO COM.
THEAMOUNT SHOWN
PU RPO88 OF ESTABLISHING
FU, 1 tIkt E D
APPLICATION FOR PERMIT
FI NANQUJILKW.
CITfO0Pff sTA!941E9R'y
DATE
JUL 3
BUILDING
ADDRESS
FIRE
ZONING
ZONE NO. OF
USB OP NEWS LII RID
R-1 PLANE 2 DUILOINO W/ Stt gIIi
LEGAL . _i 1.
YARDS APPROVED
MAIN BUILDING
IFROMC/L REFIT)
FRONT SPC Fi.�"��"//''��
R. SIDE !r FT.�dq'�/�
L. SIDE FT. `L1T3
REAR ;��FT. a`
DISTANCE BLT.
MAIN SLOGS.
VAR.
SHALL BE LESS THAN
YARDS APPROVED
ACCESSORY BUILDING
BET. MAIN 9
ACCESS. BLT
DATE
60. -FT.
0
4130
o
I HEREBY ACKNOWLEDGE TH
ANO 9TATH THAT T.ABC
IB
R THIS
q C_ D A
APPI� TION
E/TO COM.
THEAMOUNT SHOWN
PU RPO88 OF ESTABLISHING
UNDER VALUATION IS
A PERMIT FEE
FOR THE
ONLY. FO
PLV WITH ALL CITY ORDI��LA
BUILDING CONSTRUCTI
SIGNATURE OF
PERMITTEE
OULATI
VA UATION�
PERMIT FEE $
j
PLAN/
CHECK
m
a y_ X
O
AUTHORIZED AGENT
TOTAL FEE s/
p�