HomeMy WebLinkAbout2608 FAIRWAY DR - Building PermitsCITY OF COSTA MESA
��pMFq BUILDING DIVISION
'`�� 77 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Fax (714) 754-0856 • www.ci.costa-mesa.ca.us
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J � 8 FOR INSPECTtONS CALL: (714} 754-56T6
��"�� PERMIT NUMBER: E09-00127
PERMIT TYPE ELEC
APN: 43921302
JOB ADDRESS: 2608 FAIRWAY DR CM
vicinity:
STATUS: ISSUED
DATE ISSUED: 06/1212009
ISSUED BY: BJK
Suite/Unit¢
SCOPE OF WORK: CHANGE-OUT ELEC SVS AT THE REAR OF AN EXISTING SFD. 1 SVS TO 200A
NO OTHER WORK AUTHORlZED WI7H 7HIS PERMIT.
OWNER: LUNDELL, HAROLD L TR
PHONE:
APPLICANT: METZGER, ALEX
PHONE: g49-581•3342
CONTRACTOR: A M ELECTRICAL -
Address: 21392 ASPEN WOODUnit:
City/State: LAKE FOREST, CA ZipCode: 92630
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $54.00
Reinspection Fee $0.00
TOTAL FEES $54.00
Address: 2608 FAIRWAY DR Unit:
City/State/Zip: COSTA MESA, CA
Address: 21392 ASPEN WOOD Unit:
City/State/zZip: LAKE FOREST, CA
License No. 681767
� PHONE: 949•581-3342 •
CELL:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related
regulations. (Ord. No. 92-28, § t, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must wmply with all applicable wdes, and all
required inspections and final approval must be obtainetl. Failure to obtain inspections and final approval vrill result in the ezpiration of this permit.
GOOER. INSPECTIONTYPE UATE INTITIALS CODEI'� INSPEGTIONTYPE pAIE INTITIRLS
1616 Fized System Final Fire Prevention 206 Final Mechaniwl
1266 Pool Spa Final 208 Final Plumbing c �
200 Final Re-Roof 210 Final Electncal % 2 7
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 FinalOemolitian 250 Final Building/Occupancy
WORKERS' COMPENSATION DECLARATION:
I hereby aKrm under penalty of perjury one of Ihe following declarations:
❑ I have and will maintain a certifcale of consenl lo self-Insure (or workers'
com ensation, as provided for by section 3700 of the Labor Code, for Ihe
e ormance of Ihe work for which Ihis permil is issued.
I have and will maintain wnrkers' compensation insurance, as required by
ectbn 3700 of [he Labor Code, for the pedortnance of Ihe work (or which Ihis
pertnit is issued. My workers' compensation Insurance carrier and policy
number ar T
�Carrier. ���P�C �—w./��0�/Q�S +-�AS.U�21MC'P
� (Thissecfionneetlrrotbemmpletetl�(hepe �is IueOalonehuntlretltlollars($f00)wlessJ
Policy Number: ��C !.J I 3S�( 3 3 �
❑ I certify that in [he peAormance o( the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to Ihe 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.
l l.S�l/ �o r � `� �(
ApDli nCsSignaWre ale"
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNLAWFUL AND SHALL SU&IECT 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) o( Division 3 of the Business and Pro/essions Code, and
my license is in full force and effecl. /' 0 /
Lia#' ��� � Class#' l9O �7(��
�o- /c�-�q
Ca 2dor's Si atu �ale"
CONS7RUCTION IENDING AGENCY:
❑ I hereby affrtn tha[ there is a conslruction lending agency for the
perfortnance o( Ihe v.ork for which this permi� is issuetl. (Sea 3097, Civil Code).
Lender's Name:
Lender's Address:
Date
OWNER-BUILDER DECLARATIONS:
I hereby affrm tha[ under penalty of perjury ihat I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 703L5,
Business and Professions Cotle: Any city or county which requires a permit to
construct, alter, impmve, demolish, or repair any structure, prior to its
issuance, also requires the applicant foi such permit to fle a signed statement
lhat he or she is licensed pursuant to the provisions of the Contractors
License Law (Chapter 9(commencing with Section 7000) of Division 3 0( the
Business and Professions Code) or tha[ he or she is exempt therefrom antl
ihe basis (or Ihe alleged exemption. Any violalion of Section 7031.5 by any
applicant for a permit subjects the applicaN to a civil penalty of not more than
five huntlred 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
oReretl for sale (Sec. 7044, Business antl Pm(essions 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 [hrough 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
completioq the owner-builder will have the burden of proving that he or she
did not build or improve for purpose ot sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRAC7ING WITH
LICENSED CON7RACTORS [o construct the project (Sec. 7044, Business and
Pm(essions Code: The contractors License Law dces not appty to an ovmer of
property who builds or improves Ihereon, and who cont2cts for such project vnth
a contractw(s) license pursuant to the Contractors license Laws.).
❑ I am exempl under sec.
Business and Professions Code for lhis reason:
J09-Cfi (�IOII
Owner ID veri(ied hy driver's license. ❑ Yes ❑ No
Driver's License No. Expires:
Verification of Ovmership by (type of document, i.e. - property ta: bill or deed�:
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby cehify Iha� no excavation Me (5) or more feet in depth into which a
person is required to descend, vnll be made in connection with work authorized
by this permit, and that no building structure, scaffolding, falsework, a demolition
or dismantling thereot, will be more than ihirty-six (36) feet high. (Chap. 32, Grp
2, Art 2, Sec. 341, Ttle 8, Califomia Administrative Cotle).
❑ As ownerbuilder, I will no[ employ anyone to do work which would
require a permit from lhe Division of Industrial Safety, as no�ed above, unless
such person has a permit to do such work from lhe tlivision.
Applicanfs SgnaWre Date
Division of Industnal Safery Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
7. Will Ihe applican� or present or fuWre building occupant need to fle and
certify a Business Plan for emergency response lo release or threatened
release of a hazartlous material? ❑ Yes ❑ No
(Section 25505 0( the Califomia Health and Safery Code requires, with some
exceptions, Ihat a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one time during a reportetl
year a quanti[y o� hazardous materials equal [o or greater Ihan a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard tempereture and pressure).
2. Does or will lhe applicanl or present or future building occupant neetl to fle
a regisVation (orm for acutely hazardous ma[enals? ❑ Yes ❑ No
(Section 25533 of lhe Califomia Health and Safety Code, wilh some
exceptions, requires registra[ion wilh the Cos[a Mesa Fire Department by
each business which at any one time has on hand a quantiry ot awtely
hazardous materials equal to or greater than a weight of 500 pountls, or a
volume ot 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 malerials)? ❑ Yes ❑ No
(Section 25534 of the Califomia Heal[h and Safety Code provides that [he
Costa Mesa Fire Depahment may require Ihe preparation, certification and
filing with the Fire Department of an RMPP by businesses which are required
ro regis[er acutely hazartlous materials with the Fire Department.
4. If an RMPP is presently required, has Sec[ion 25534 of the California
Health and Sa(ety Code been fulty complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require tor
the work which is the subjecl of this application a permit for such construction
or modifcation trom the South Coast Air Quality Management District or from
any other air polWtion control disMct or agency? ❑ Yes ❑ No
(Section 658502 of the CaliTomia Govemment Code requires that the requestetl
intortnation be fumished on applications for non-residential buildinq pertnits).
6. Will any part o( lhe facility to be constructed under this permit be within
1000 feet from the outer bountlaries o( a school? ❑ Yes ❑ No
Qf'yes", the facility must meel lhe requirement of Sec[ions 25534 and 42303
of the Califomia Health antl Safety Code).
7. If a pertnit from lhe Sou[h Coast Air Qualiry Management District or other
air pollution contml district or agency is required for the work which is the
subject of this application, have all of the tlisclosures prescribetl by California
Health and Safery Code Section 42303 been made? ❑ Yes ❑ No
8. Qf "yes", attach certifcate of compliance from the appropriate air polWtion
control oKcer).
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.
Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalry of perjury thal I have read this application and state that
the information given is correcL I agree to compty with all state laws and city
ordinances relating to building construction, and authorize representalives 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 builtling
authorized by this permit uNil final inspec[ion.
ignawre o Leg wer(s) Daie
. � � G -(,� -0 y
�' An IorAut�otlz OApPlican� - . Date . -
(714) 754-5273 • faz (714) 754-4856 • www.ci.costa•mesa.ca.us 77 FAIF DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
JobAddress: 2608 FAIRWAYDR
Suite:
Vicinity: GARAGE ONLY
Parcel Number: 43921302
Applicant FRAME, CRAIG
Address: 1542 SIERRA ALTA
SANTA ANA, CA - �
Owner: LUNDELL, HAROLD L TR
Address 2608 FAIRWAY DR
COSTA MESA, CA
Contracror. FRAME ROOFING
Address: 1542 SIERRA ALTA
SANTA ANA, CA
Zip: 92705
Arch :
Address:
Zoning:
ISSUED BY:
Phone: (714) 730-0569
Zip: 92705
Phone:
Zip: 92627
Phone: (714)730.0569
License: 661176
Eng:
Address:
Status: ISSUED
Applied: 12/05/2001
Issued: 12/OS/2001
Phone: Phone:
Zip: license: License:
SCOPE OF PERMIT
� REROOF GARAGE ONLY: T/O EXISTING 2 LAYERS OF COMP,�REPAIR SHTG AS NEEDED, 1 LAYER 30# FELT, APPLY
"30-YEAR DIMENSIONAL SHINGLES." 4 SQUARES
Plan Check: $0.00
Permit: $32.65
SMIP Res: $0.50
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $33.15
SETBACKS
MAINSTRUCTURE Front 0-0
ACCESSORY Front 0-0
PARKING ex�stinq: a
NOTES:
Rear 0-0
Rear 0. 0
Reouired: 0
FEE SUMMARY
PLANNING & ZONING
Lefl 0- 0
LeR 0- 0
Pr000sed: 0
Calc Valuation:
Claim Valuation:
Right 0-0
Right 0-0
$800.00
$800.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requiremenis under Calitornia 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 1 BO days, or it 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 InsDections and tinal approval will result in the expiration of this pertnit.
FOR INSPECTIONS CALL: (714) 754-5626
taaas �eroo�
WORKERS' COMPENSATION DECLARATON:
I hereby attirm untler penalry of perjury one oi ihe tollowing declara�ions:
❑ I have end will melntain e certificeta ol consent to seN-Insure tor workers' compensation, es proviAetl far Cy section 3700 of the Labor Code, for the pertormence of Ihe
work fo� which t�is Oermit is issuetl.
'CX I heve en� wlll maintaln workers compensatlon insurance, as requiretl by section 3700 oi ihe Lebor Cade, for �he pertortnance of the work lor which this pertnit is issued.
�` My workers ca ensatlon Insurence cardar entl policy number ere:
ce��a�: �RTi1`i� r�'—�an
Policy Number: �2i3 � Z 3% ' �%
(Thls section neetl nat be complefed il fhe permit Is valuetl at one hundred dollars ($100) ar less.) '
❑ I certity that in the pertormance of the work for which this permit is issueQ I s�ell not employ any pereon In eny manner so as to become subject to the workers'
compensatlon laws of Celifornle, entl epree th i ultl Decome sub�ect to lhe warkers' compensatlon provisions ot Section 3700 oi the Labor Cotle, I shall forthwith
cnmply with NeSe provisions. j�Y
Appliwnt SlpnaNra: ! _� Date: I7 —O S b�
WARNING: FAILUPE TO SECURE WORKERS' COMPENSAiION COVERAGE IS UNL4WFUL AND SHALL SUBJEGT AN EMPLOVER TO CRIMINAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED
TV10USlWD DOLURE R��•�)� �N ADDITION TO TME WST OF WMPENSATION, �AMqGES AS PROVIOED FOR IN SECfION 31O80F iHE IABOR CODE, IMEREST, AND ATTORNEV'S FEES.
LICENSED CONTRACTORS DECLARATON:
I hereby aHirtn that I am licensetl un r rq+�,�q� yt Chapter 9(wmmencing with Section 7000) of Division 3 0l the Business and P fessions ode, antl my license is In full
rome eoa enecc uc. a !/-/—Gc cieu x �— 3�
Contrectofs SlgnaNre: _,Q — Dete: / L —f --�+ �
�
GONSTRUCTION LENDING AGENCV:
❑ I hereby aXlrm ihat ihere is e construction lending egency for ihe peAormance ot the work for which this permit is issued. (Sec. 3097, Civil Gode).
Lendefs Name: Lendefs Address:
Signature: Date:
OWNER•BUILDER DECLARATIONS:
I �ereby ettirm that under penelty of perjury that I am E%EMP7 FROM THE CONTRACTORS LICENSE LAW tor the lollowing reason (Sec. 7031.5, Business and Protesslons
Code: Any ciry or wunry which requires e partnit to consiruct, alter, improve, tlemolis�, or repair any structure, prior to its issuance, also requires the applicant tor such permit
to file a signed stetament thet ha or sha Is Ilcensed pursuam ro the pmvisions of the Conirectors Llcense Lew (Chepter 9(commencing with Section 7000) of Dlvlsion 3 of ihe
Business end Prolessions Cotle) or ihet he or she is exempt fheretrom and the basls tor the alleged exemption. Any violetion of Section 703L5 by eny epplicent for e pertra.
subjecis iha applicant to e civll penelry of not more than fiva huntlred dollars ($500).):
❑ I, as owner oi Ihe pmperty, or my employees with waqes as iheir sole compensation, WILL DO 7HE WORK, and ihe sirucWre Is not intended or oHeretl tor sele (Sec.
7044, Business end Professions Cotle: The Contractors License Law tloes noI apply to en owner of property who builds or improves thereon, end who tloes such work
himsell or herselt or thmugh �is or her own employees, provitled that such impmvemems are not Intendetl or oHered for sele. If, however, ihe building or Impmvement is
soltl within ona year of completion, the owner-builder will have the burtlen of proving that he or she ditl not build or improve for puryose ol sale.).
❑ I, es owner ol the property, am E%CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to consirucl lhe project (SacJ046, Business and Protessians
Cotle: The contrectors License Lew tloes not epply to an owner of pmperty who builtls or Improvas thereon, antl who contracts for such project with e conirector(s)
licensa pursuent to lhe Con�recbrs Litense Lews.).
❑ I am eaempt under sec. Business end Professions Codo for this reason:
Signature: Date:
Owner ID venfied by tlriveYs license. ❑ Yes ❑ No Drivefs License No. Expires:
Vedficetlon o1 Ownership Dy (lype ot tlacumeni, i.e. - property tarz bill or tleetl):
DIVISION OF INDUSTRIAL SAFETY PERMR CERTIFICATION:
❑ I hereby cenify that no excavetion fiva (5) ar more leet in depth into which e persan Is requireC to descend, will be mede in connection with work autharized by thls
pertnil, and Ihat no 6uilding structure, scaHolding, lalsework, or damolition or dismantling Ihereol, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Tltle 8, Celilornia Atlminis�re�ive Cotle).
❑ As owner-builder, I will nat employ anyone to do work which would require e permit from Iha Division af Intlustrial Sefery, as noted above, unless such persan hes e
permit to do such work from the division.
Signature: Date:
Division of Intlustnel Safety Permit Numbar:
CERTIFICATE OF COMPLIANCE AND AUTHORIZA710N OF ENTRV: I certify under penelry of perjury thet I heve read this application and stete ihet ihe Information given is
correct. I egree �o comply with ell state laws end ciry ortlinances releting to building construction, end authorize representatives of the City ol Costa Mese to enter upon lhe
ebove-tlescribed property tor inspection puryoses. I agree not to occupy or allow occupancy of eny buildinq euthorizetl by this permit until final inspection.
COOE �. INSPECTONTYPE
1616 Fixetl Sysiem Final Fire Preventian
1266 Pool Spa Final
200 Final Ra-Rool
201 Finel8locWReteining Well
202 Final Factory Fire Place
203 Final Sign
204 Final Demalition
PAIF. It�Lfl
� �
Date
/2—�—�I
oa�e
CODE� INSPECTIONTYPE
206 Final MechanlCal
20B Pinel Plumbing
210 Finel EIBCIncal
212 Finel Fire Prevention
220 Final Planning Approval
222 Final Site
250 Finel Building/Occupancy
� �
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 26OH FAIRWAY DR
Suite:
Vicinity: RESIDENCE ONLY
Parce� Number: 43921302
npplicant: FRAME, CRAIG
Adtlress: 7542 SIERRA ALTA
SANTA ANA, CA
Owner: LUNDELL, HAROLD L TR
Address 2606 FAIRWAY DR ,
COSTA MESA,CA
Contractor: FRAME ROOFING
Address: 1542 SIERRA ALTA
SANTA ANA, CA
Zip: 92705
Arch :
Address:
Zoning:
ISSUED BY:
Phone: (714)730-0569
Zip: 92705
Phone:
Zip: 92627
Phone: (714)730-0569
License: 661176
Eng:
Address:
Phone:
Status: ISSUED
Applied: i2/OS/2001
Issued: 12I05/2001
Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF RESIDENCE ONLY: T/O EXISTING 2 LAYERS OF COMP, REPAIR SHTG AS NEEDED, 1 LAYER 30# FELT,
APPLY "30-YEAR DIMENSIONAL SHINGLES." 18 SQUARES - � -�
Plan Check: $0.00
Permit: $9725
SMIP Res: $0.50
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $97.75
SETBACKS
MAINSTRUCTURE Front 0-0
ACCESSORY Front 0- 0
PARKING Existin : 0
NOTES:
Rear 0- 0
Rear 0- 0
Required: 0
FEE SUMMARY
PLANNING & ZONING
Left 0- 0
Left 0- 0
Proposed: 0
Calc Valuation:
Claim Valuation:
Right 0-0
Right 0-0
$3,500.00
$3,500.00
NOTICE: The work authorized by this permit shall comply with al�l applicable handicap access requirements under Califomia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-27-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 780 days, or if work is suspended or abandoned
for a period of 1 BO days.
INSPECTIONS: In order for ihe work authorized under ihis permit to be considered legal, such work must comply with all applicable codes, and all
requlred inspectlona and flnal approval must be obtained. Failure to obtain inspections and final approval will result in the expiiation of ihis permit.
i FOR INSPECTIONS CALL: (714) 7545626
>qqg.qg (gqp�
WORKERS' COMPENSATION DECLARATION: '
I horeby affirtn under penalty of perjury ona of the tollowing declarations:
❑ I heve antl will maintain a certificate ol consent to selt-Insure for workers' compensetion, es providetl for by section 3700 of ihe Labor Code, for ihe pertortnance ot Ihe
work tor which this Dermit is issuad.
� I have and witl maincain workers' compensation insurance, as requiretl by section 3700 ot the Lebor Code, for the perfortnance of ihe work for which ihis pertnit Is luued.
My workers' compensation /Insuranca carder end policy` �number ere:
Carner. ' !� % ir%� ��!/N y Policy Numbec I ti�LZi I— ��
(This section need nat be cnmpl ted il fhe pe�mit is velued et one huntlred dollers ($100) or less.)
❑ I certily that in the Oahormence of the work for which this permit is issueQ I shall not employ any person in any manner so es to becoma subject to the workers'
compensation laws of Celifomia, entl egree t If I shoultl becoma subJect to the workers' compansation provislons ot Section 3700 of Ihe Labor Code, I shall forlhwith
Comply wi�h these provisions.
Applicant Signature: � Dare: � 7i' S—O�
WAfiNINO: FAILURE TO SECURE WORKEPS' COMPENSATION CAVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOVER TO CRIMINILL PENALTIES AND CIVIL FINES UP TOONE HUNORED
TFiOUSAND OOLLARE (5100,000), IN ADDITION TO THE COST OF CAMPENSATION, DAMAGES AS PROVIDED WR IN SECTIIXJ 3�O60F THE IAeOR CODE, IMEREST, AND AiTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aHirtn that I em licensetl untler provisic
torca end ettect Lia k
Contractor's Signeture: _
of Chapter 9(commencing with Section 7000) of Division 3 of Ihe Business entl Pmfessions Code, and my license is in tull
Class M � — 3 g
De�e: /z- – S--O/
CONSTRUCTION LENDING AGENCV:
❑ I here6y aHirm that thare is e constmction lending agency for the pertortnance of the work tor which this pertnit is issued. (Sec. 3097, Civil Code).
Lender's Neme: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby aflirm Ihe� untler penalry oi perjury tha� I am EXEMPT FROM THE CONTRACTORS LICENSE LAW tor the following reeson (Sec. 7031.5, Business end Professions
Code: Any ciry or counry w�ic� requires a pertnit to consiruct, alter, improve, tlemolish, or repair any structure, prior to its issuance, also requires the applicam tor such pertnit
to file e signetl statement ihat ha or she Is Ilcensed pursuent to ihe provisions oi ihe Comrectors License Law (Cheprer 9(commencing with Secllon 7000) of Division 3 ot [he
Business and Protessions Code) or ihat he or she is ezempt Iherefrom and the besis for ihe alleged ezemption. Any violation ot Section 7031.5 by any epplicant tor a perrt+
subjecis Ihe applicant to a clvil penalty of no� more than five hundretl tlollars ($500).):
❑ I, as owner ot the properry, or my employees with wages es their sole compensation, WILL DO TME WORK, end the strucWre is not intended or oHered for sele (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builtls or Improves iheraon, antl who does such work
himself or herself or through his or her own employees, provided ihat such improvements are not Intended or oflered for sale. It, however, the builtling or improvement is
soltl within one year of completion, ihe ownerbuilder will have ihe burden ot proving ihat he or sha tlitl not build or improve tor purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Cotle: The coniractors Ucense Law does not apply to an owner of pmparty who builds or improves thereon, antl who contracts for such project with a contrector(s)
license pursuant to the Con�rectors License Laws.).
❑ I am exempt under sec.
Signature:
Owner ID verifietl by dnvefs license. ❑ Ve5 ❑ No
eusiness and Professions Code for this reason:
Veriticetion of Ownership by pype of documem, i.e. - property tex bill or deed):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
Drivets License No.
Da�a:
Expires:
❑ I hereby certify that no excavation five (5) or more feat in depih into which e person is required to descend, will 6e made in connection with work authorized by this
permit, antl thal no building simcture, scattolding, falsework, or demolition or dismantling ihereof, will be more than ihiny-six (36) teet high. (Chap. 32, Gry 2, Art 2, Sec.
341, Title B, Calitornia Adminisirative Cotle).
❑ As owner-builder, 1 will not empioy anyone to do work which would require a permit from the Division of Indusinal Safery, as noted a6ove, unless such person has e
permit to do such work irom the division.
Signature: Date:
Division of Intlusinel Safely Permit Number:
CERTIFICATE OF COMPLIANCE AND AUIHORIZATON OF ENTRY: I cehity under penalty oi perjury that I have read ihis epplication end state thet ihe information given is
correct. I egree to comply with all state laws end city ordinances relating to building cons�mction, and euthonze represen�atives of ihe Ci�y of Cos�a Mesa �o en�er upon �he
above-described proDerty for inspection puryoses. I agree not to acupy or allow occupancy oi any building authorized by ihis permit un�il final inspection.
�atura Of ef gdh9 ew( �(s) Date
�_ / Z - S- -�/
And/Or Authodzed Applic'am Date
COOE1• INSPECTIONTYPE
1616 Fixetl System Final Fire Prevention
1266 Pool Spa Final
200 Final Re-Root
201 Final Block/Retaining Wall
202 Final Fectory Fire Place
203 Final Sign
204 Final Demolition
pRTE �MRIRLS
�� (� �
CODEN INSPECTIONTYPE
206 Final Mechanical
208 Final Plumbing
210 Final Electrlcal
212 Final Fire Prevention
220 Final Planning Approval
222 Final Site
250 FinalBuilding/Occupancy
P�IE INTffIRLS
R "" �2483
� ,.
' EOSTA MESA BUILDING-SAPEf7 DEPARTMENT
P. O. BOX 91] CO3TA MEHA. CALIFORNIA
Fo► Applicant ro Fill In Completely
TYPE OR,PRINT
� MAIL
STATE
LIC. NO
SIZE
OF LOT
USE OF
COSTA MESA, CALIFORNIA
NE
�
�
DESCRIPTION OF WORK
a
� XEREBY ACKNOWL6D08 THAT I�MAVE PPaD THIS APPLICATION
•NO 6TATE THFT TH6 ABOVH 18 CORRECT AND AGREE TO COM.
PLY WITH ALL qTY ORUINANCE9 ANO BTATg y�WB RHOULATINO
BUILOINO CONSTRUCiION,p.�. /'�
P RMnITTE E � �='"W' � • �,/� � ��O
AUTHORIZED A6ENT �/��,{n l ��
�
FEE RECEIVED �
�UN 2 2 1964 5
fINANCE DEPT. a
�Pfd�'���o�N� e�� �
For Ofiice Use Only �U '
RBCEIP�NO. �MIT,N� ti �
6DBY OGT fl8C 2 pATE189�U6D�
10�4%�/� �n ,4 3 -/v�% o
APPROVED
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use on rvew
` em�oina
YARDS APPROV ED
MAIN BUILOIN�
tOMC/LSTREET� ��
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6HALL BE LE33 THAN �
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YARDSAPPPOYED
ACCESSORYBUfLDING i
DISfANCE BET. I BET.
MAIN BLD6S. ACCE
VAR.�{' OATE
TNE AMOUNT BXOWN UNDEp VALUATION 19 FOp TH8
PIIpPOSE OF EBTABLIBXINO M1 PEPMIT FE6 ONLY.
VALUATION nn
/�(� PERMIT FEE $ N m ` �
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$ O O fl A C �P/�• �� �7
f/ ......... «< � LL�Oi/
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COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 7P00 � COSTA MESA. CALIFORNIA 9RC26
For App►lcanf Po ftll In Completaly
TYPE OR PRINT
]DRESII ��Z�pO ��A � R W W� ��
COSTA MEBA. CALIFORNIA
NNER � . 1..��% NO��-L'
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c nren op�airt[Rp % a7�W �'� R�AR YA D �
DIDB YARDI L[PT � � RI6XT �
DESCRIPTION OF WORK
� EXTERIOR
AND WORjC TO O6
e
FEE RECEIVED
„Q()�+ 2 2 1964
FINANCE DEPT.
,�a��r[dfri (iQ�FP�df�iP
BUILDING
For OHica Uso Onfy
R[C[Irf NO, PC� � IT 1�p.�
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A. P. NO. �! N' I d� ��% v .
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NOTR: NO GV! OV[RHAN6 SHALL BE LE86 THAN
80' TO BIDi ! RBAR P. L.
ewvec
ALLOW[D �U.B.C.REQUIRHMED
YARDHMPROVHD YARDSAPPROVED
MAIN BUILOIN6 ACCEL80RY BUILOII
vwR.#
owre
t HEP6BY ACKNOWL6D06 THAT I NI�VB RGD TN18 APPLIGTION TNQ AYOIIM 9XOWN UNOBR
ANO BTATB THAT TN6 AGOV6 U CORPBCT�ANO AOpB[ TO COM• �YPPooB OP �BTA�LIBNINO
PLY W�TX ALL CITY ORDItUNCiY AND YTI1T[ U1W3 R[OULATIMO yALUATION
BYILOINO CONBTRYCTIOX.
SIQNATURE OP / PERM
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