HomeMy WebLinkAbout1100 DENNIS DR - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.usING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 1100 DENNIS DR
Suite:
Vicinity:
Parcel Number: 41207446
Applicant: SEMERDJIEV, GEORGE N
Address: 1100 DENNIS DR
COSTA MESA, CA
Owner: SEMERDJIEV, GEORGE N
Address 1100 DENNIS DR
Contractor:
Address:
Zip:
Arch :
Address:
COSTA MESA, CA
Phone:
Zoning: R1 R1
Phone: 714-751-4626
Zip: 92626
Phone:
Zip: 92626
Phone:
Status: ISSUED
Applied: 12/02/2002
Issued: 01/06/2003
Licenser
Eng: ROBERT TRIVISON
Address:
Phone: 562-925-5532
Zip: License: License: 52398
SCOPE OF PERMIT
ADD 89 SQ.FT 2ND STORY BATHROOM TO EXISTING SINGLE FAMILY RESIDENCE.
MINOR DESIGN REVIEW NOT REQUIRED FOR 2ND STORY ADDITION BECAUSE PROPERTY IS ZONED PDR -LD.
40% OPEN SPACE REQ; 46% PROVIDED '
Plan Check:
$108.71
Permit:
$167.25
SMIP Res:
$0.82
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total: $276.78
SETBACKS
MAIN STRUCTURE Front 11-0
ACCESSORY Front 0-0
FEE SUMMARY
PLANNING & ZONING
Rear 5-0 Left 5-0
Rear 0-0 Left 0-0
Calc Valuation: $8,223.60
Claim Valuation: $0.00
Right 5-0
Right 0-0
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) 7545626
2446-48 (aW)
1
DECLARATIONS
WORKERS' G'SMPEM.5ATION DECLARATION: R
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 Wis permit is Issued.
❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if me permit Is valued at one hundred dollars ($100) or less.)
Pa 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 Callfomla, an a ee th t It I sh become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions. /
Applicant Signature: Date: az/ep6l ��2
WARNING: FAILURE TO SECURE WORK RS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CR IVIN PENALTIES AND CIVIL RNES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE CDST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR OODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
farce and effect. Lic. a Class P
Contractors Signature: Date:
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).
Lenders Name: Lenders Address:
Signature: Data:
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the fallowing reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License ws.).
❑ 1 am exempt under sec. Business and Professions Cade for this reason:
Signature: Date: O O
Owner ID verified by dives license. Yes ❑ No Driver's License No. Expires:l".SO'
Verification of Ownership by (type of doculark
i.e. - property tax bill or deed):
DIVISION OFINDUSTRIAL SAFETY RMIT 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 Callfomia 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).
......_...................._.._......... ........-__........................... _._............. _.._._...................... -_-.............. _.._.__-_._........................ _..-.......................... _._... _..—_".._....................... _.... _.............. _.......I...._.................._._.
2 Does or will the applicant or present or future building occupant need to file a registration forth 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 Mend 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 al standard temperature and pressure).
........................ .................................................................. ................................................................................................................................................................................................................................................. -..............................................
3 Does or will the aGGplicant or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
EJ Yes ❑ No
(Suction 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 It en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complietl wlih7 ❑ 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 a ernit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ LJ
Yes No
(Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
..................... ...... .................................................................................. ......-................... ...................................................... ................. ...................................................................................................... .......................................................... 1...........
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 II 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? 7 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 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 in ec' $as. ee not to Occupy or allow Occupancy of any building authorized by this permit until final inspection.
o�/o�z0D3
Signature Of Legal Owner(s) Date/
And/Or Authorized Applicant Date
CODE 0. INSPECTION TYPE MH lid CODE d INSPECTIONTYPE PAIL INTMALS
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/Relaming Well 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--
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
MECHANICAL PERMIT
Job Address: 1100 DENNIS DR
Suite No
Vicinity:
Parcel Number: 41207446
Applicant: SEMERDJIEV, GEORGE N
Address: 1100 DENNIS OR
Phone: 714-540-4932
COSTA MESA, CA Zip: 92626
Owner: SEMERDJIEV, GEORGE N
Address: 1100 DENNIS DR
Phone:
COSTA MESA, CA Zip: 92626
Contractor: ' OWNER -BUILDER
Address:
Phone:
Zip:
License: 000000
ISSUED BY:
SCOPE OF PERMIT
ADD 89 SQ.FT 2ND STORY BATHROOM TO EXISTING SINGLE FAMILY RESIDENCE.
MECHANICAL TO INCLUDE: 1 VENT FAN" , ..
REF.: B02-01944
Status: ISSUED
Applied: 01/06/2003
Issued: 01/06/2003
FEE SUMMARY
Quantity
ISSUE FEE
$23.50
Quantity
Inst FAU <100 k BTU
$0.00
0
Inst FAU >100 k BTU
$0.00
0
Repair/ Alt Cooling/Heat
$0.00
0
Inst / Rep. Recess Wall HV
$0.00
0
Refdg Sys <100 k BTU
$0.00
0
Refrig Sys >100 k BTU
$0.00
0
Gas Piping
$0.00
0
Factory Fireplace
$0.00 -
0
Hood w/Meth Exhaust
$0.00
0
VAV Box
$0.00
0
Vent Fan / Single Duct
$7.25
1
Appliance
$0.00
0
Fire Dampers
$0.00
0
Smoke Dampers
$0.00
0
Inst or Relocate Appl Vent
$0.00
0
Air Handlers < 10000cfm
- $0.00
0
Air Handlers> 10000cfm
$0.00
0
Floor Furnace
$0.00
0
Floor or Suspend Heater
$0.00
0
Status: ISSUED
Applied: 01/06/2003
Issued: 01/06/2003
FEE SUMMARY
_
Quantity
Repair / Alt Absorbtion Unit
- $0.00
0
Repair / Alt Refrigeration Unit
$0.00
0
Ventillation System
$0.00
0
Evaporative Cooler
$0.00
0
„ Commercial Incinerator
$0.00
0
" Domestic Incinerator
$0.00
0 "
Compressors / Absorption Systems, ,
Up to 3 hp / 100 k BTU
$0.00
0
3 T 15 hp/500k BTU -
$0.00
0
15 To 30 hp / 1,000 k BTU
$0.00
0
30 To 50 hp / 1,750 k BTU
$0.00
0
Over 50 hp / Over 1,750 BTU
$0.00
0
Boilers -
-
- Up to 3 h
$0.00
0
3 To 15 hp
$0.00
0
15 to 30 hp
$0.00
0
30 to 50 hp
$0.00
0
Over 50 hp
$0.00
0
Other Mechanical Fee
Investigation Fee
$0.00
Plan Check Fee
$0.00
Reinspection Fee
$0.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days. .
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626 '
2446-46 (6/00)
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the fallowing 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.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3701 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed If the permit is valued at one hundred dollars ($100) or less.)
l4� 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'
T compensation laws of California, an agar If I she I become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions. n
Applicant Signature: _ Date: /��i�/.WrJi
WARNING: FAILURE TO SECURE WORKE6S"CCPAPENSATr8N COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMIPAL PEN TIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
force and effect. Lid. 8 Class N
Contractors Signature: Date:
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).
Lenders Name: Lender's Address:
Signature: Data:
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 01 the propeny, 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:
Owner ID verified by drivers lice se. Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of docum t, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERM 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, Ttle 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 25593 of the California Health and Safety Code, with some excetions, 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 en RMPP i9 presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
........................ ......................................................................................................................................................... ................................................__................................................................. ....................................................................................
5
as or will the applicant or present or future building occupant require for the work which is the subject of this a plication apermil for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Byes 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).
W.W. 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 [INo
.... ......................... ..... .... ................................. .......................................................................................................................... ......................... .........................................
8 (If yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the intonation given is
correct. I agree to comply with all state laws and city o Inances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspe to
as.
I enol to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of L al Owners) Date
And/Or Authorized Applicant Date
coli t. INSPEOTrOffTYPE OATS IMMALS CODE INSPECTION TYPEILeg INTrnALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Rcof 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
(714) 754.5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
PLUMBING PERMIT
Job Address: 1100 DENNIS DR
Suite No
Vicinity:
Parcel Nunmber: 41207446
Applicant:
SEMERDJIEV, GEORGE N
Applied:
01/06/2003
Address:
1100 DENNIS DR
QTY
0
AMT
ISSUE FEE
Phone:
714-540-4932
Laundry Tub / Washer
COSTA MESA, CA.
Zip:
92626
Owner:
SEMERDJIEV, GEORGE IN
$0.00
Backflow Preventers
Address
1100 DENNIS DR
?-Trap
$0.00
Bathtub
$0.00
Phone:
Pressure Regulator
'
COSTA MESA, CA
Zip:
92626
Contractor:
OWNER -BUILDER
Connect (Ice,Soda,etc)
$0.00
Address:
Receptors
$0.00
Dental Units
$0.00
0
Phone:
$0.00
Dishwasher
$0.00
Zip:
Sewer Cap for Demo
$0.00
Drain, Floor
License:
000000 ,
Sewer Connect
$0.00
Drain, Rainwater
$0.00
Arch / Eng:
Sewer Private Line
$0.00
Drain, Roof
Address:
0
Shower
--
Drinking Fountain
$0.00
Phone:
Sink, bar
$0.00
--- -
�- Zip:
_ ..
License:
Status:
ISSUED
Applied:
01/06/2003
Issued:
01/06/2003
SCOPE OF PERMIT
ADD 89 SQ.FT 2ND STORY BATHROOM TO EXISTING SINGLE FAMILY RESIDENCE.
PLUMBING TO INCLUDE: 1 SHOWER, 1 WASH BASIN AND 1 WATER CLOSET. REF.: 1302-01944
QTY
-
AMT
FEE SUMMARY
0
AMT
QTY
0
AMT
ISSUE FEE
'$23.50
0
Laundry Tub / Washer
$0.00
Backflow, irrigation
$0.00
0
Landscape Irrigation
$0.00
Backflow Preventers
$0.00
0
?-Trap
$0.00
Bathtub
$0.00
0
Pressure Regulator
$0.00
Clarifier System
$0.00
0
Process Piping (per 10 ft)
$0.00
Connect (Ice,Soda,etc)
$0.00
0
Receptors
$0.00
Dental Units
$0.00
0
Septic Tank
$0.00
Dishwasher
$0.00
0
Sewer Cap for Demo
$0.00
Drain, Floor
$0.00
0
Sewer Connect
$0.00
Drain, Rainwater
$0.00
0
Sewer Private Line
$0.00
Drain, Roof
$0.00
0
Shower
$9.80
Drinking Fountain
$0.00
0
Sink, bar
$0.00
QTY
-
AMT
QTY
0
Sump Pump
$0.00
0
0
- Swimming Pool
$0.00
0
0
Trap Primer -
$0.00
0
0
Urinal .
$0.00
0
0
Vacuum Brkr Bkflow(1-4)
$0.00
0
0
Vacuum Brkr Bkflow(5+)
$0.00
0
0
Wash Basin
$9.80
1
0
Wash Basin Set
$0.00
0
0
Waste and Vent System
$0.00
0
0
Water Closet (Toilet)
$9.80
1
1
Water Heater / vent
$0.00
0
0
Water Piping (Inst or Rep.)
$0.00
0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
2446-46 (6/00)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm Under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is Issued.
❑ 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 Carder and policy number are:
Carder: r Policy Number:
(This section need not be completed it the permit is valued at one hundred dollars ($100) or less.)
AI 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 apre h I should b ome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
/ O/�
Applicant Signature: Date: alla,6_IZA" .3
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full
force and effect. Llc. N Class x
Contractor's Signature: Date:
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: 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 pernit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
I, as owner of the property, of my employees with wages as their sola 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 ownef of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. 1 Business and Professions Code for this reason:
Signature: Date: QD
Owner ID verified by driver's li nse. es ❑ No Driver's License No. Expires: D
Verification of Ownership by (type of docum t, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMI • 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) 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 d0 such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the app(cant 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).
.......................
................................................ i a l............
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? [:1 Yes ❑ No
5 Does or will applicant or present or future building occupant require for the work which is she subject ,appllcailon eppermii for such construction or modification
the Southh Coast Air Quality Management District or from any other air pollution control district or agency? L-I 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).
....................................................................................................................................................................................................................................................................................................................-....................,.........................................
8 Will any part of the-fa, cility 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? [I Yes [I No
...................................................................................................................................................................................................................................................................................................................................................................................
......
8 (if "yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree t0 comply with all state laws and city ord' noes relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for insp do s. of to occupy or allow occupancy of any building authorized by this permit until final inspection.
Ignature Of Legal Owner(s) r^T Date
And/Or Authorized Applicant Date
CODE I. INSPECTION TYPE PM JNIMIAL$ CODE INSPECTION TYPE INITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
p
1266 Pool Spa Final 208 Final Plumbing _pLL
200 Final Re'ROOf 210 Final Electrical
201 Final Block/Retaining Well 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
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address:
1100 DENNISDR
Suite No
01/06/2003
Vicinity:
01/06/2003
Parcel Nunmber:
41207446
Applicant:
SEMERDJIEV, GEORGE N
Address:
1100 DENNIS DR
ISSUE FEE
COSTA MESA, CA
Owner:
SEMERDJIEV, GEORGE N
Address
1100 DENNIS DR
Temp service test
COSTA MESA, CA
Contractor:
OWNER -BUILDER
Address:
0
Phone: 714-540-4932
Zip: 92626
Phone:
Zip: 92626
Phone:
Zip:
License: 000000
ISSUED BY:
SCOPE OF PERMIT - -
ADD 89 SQ.FT 2ND STORY BATHROOM TO EXISTING SINGLE FAMILY RESIDENCE.
ELECTRICAL TO INCLUDE: 4 LIGHTING FIXTURES, 2 OUTLETS, AND 2 SWITCHES. REF.:
B02-01944
Status:
ISSUED
Applied:
01/06/2003
Issued:
01/06/2003
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) 7545626
FEE SUMMARY,
Quantity
Quantity
ISSUE FEE
$23.50
Temp Dist System I Lighting
$0.00
0
Temp service test
$0.00
Busway /100 It
$0.00
0
Res. a/c package -
$0.00
- Standing Section
$0.00
0
New Res (1-2 units)
$0.00
0
Misc Electrical Equipment
MOO,
1 . 0
New Res (3+units)
$0.00
0
Transformers up to 1 kva/kw
$0.00
0
Pool / Spa
$0.00
0
................up to 10 kva/kw
$0.00
0
Lighting Fixts
$4.40
4
.................up to 50 kva/kw
$0.00
0
Recept Outlets
$2.20
2
.................up to 100 kva/kw
$0.00
0
Switches
$2.20
2
..................over 100 kva/kw.
$0.00
0
Non Res Appl
$0.00
0
Low Voltage Equipment
$0.00
0
Res App]
$0.00
0
Low Volt Wiring System / Ckt
$0.00
0
Service to 200a
$0.00
0
Misc. Conduit
$0.00
0
Service to 1000a
$0.00.
0
Misc. Conductor
$0.00
0
Service over 1000a
$0.00
0
Circus ( gen or ride)
$0.00
0
Motors to 1hp
$0.00
0
Circus (mech ride or lights)
$0.00
0
Motors to 10hp
$0.00
0
Christmas Tree Stand
$0.00
0
Motors to 50hp
$0.00
0
Fireworks Stand
$0.00
0
Motors to 1 00h
$0.00
0
Other Electrical Fee
$0.00
Motors over 100hp
$0.00
0
Communication drops
$0.00
0
Investigation Fee
$0.00
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) 7545626
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a ceriflcate 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.
❑ 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: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars ($100) or less.)
IxI 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 gr If I s uld become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions. //O�/ �nO-3
Applicant Signature: - Date: /�Y
WARNING: FAILURE TO SECURE WORKE ' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
force and effect. Lic. M Class a
Contractors Signature: Date:
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).
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 pernit 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
su acts 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.).
❑ 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 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. AS ❑ No Drivers License No. Expires: C
Verification of Ownership by (type of docu t, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PE IT CERTIFICATION:
❑ 1 hereby certify that no excavation IN(5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
hat
permit, and tno builtling structure, caffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Ttle B, 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 Pernit 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 Califomia 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 o1
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 en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Ves 0-140-
............................._.............................. ............................................... ................................_.................................. ........................................................................... .............................................................................................................. I'll ...............
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a $parmit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? UYos U No
(Section 65850.2 of the California Goverment Code requires that the requested Information be furnished on applications for non-residential building permits).
.............. _._.......................................................... __......_.................................__......................... —...........................__.__ ............................ _._..;i.................................................._f........._.._....................... _............_.__........
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? Vas ❑ No
(If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
W.W...... ......................................................................................... ... ....._........................................._...................................................................................................
.....................................................
7 a a permit from the South Coast Air Quality Management a Heal or other air pollution control 303 been
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? ❑Ves ❑ No
.................................s".....................ific.._...................................._...._.........................__................llut....._.................offi......................__................................_........................._.__._..............................................._.................._.................
8 (If yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-doscribed property for ins cti oses. a not to occupy or allow occupancy of any building authorized by this permit until final inspection.
ofliea200 3
,.Signature Of Legal Owner(s) T� Date
And/Or Authorized Applicant Date
CODE s. INSPEgTIONTyPE 2AM IMIAL$ CODE INSPECTION TYPE 2M INTITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Root 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
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 1100 DENNIS DR Status: ISSUED
Suite: Applied: 02/19/2002
Vicinity: Issued: 02/19/2002
Parcel Number. 41207446 Zoning: R1 R1
Applicant: ALAJOKI, JOHN ISSUED BY:
Address:
Phone: _
Zip:
Owner: SEMERDJIEV, GEORGE N
Address -1100-DENNIS DR _
Phone:
COSTA MESA, CA Zip: 92626 ,
Contractor: JA ROOFING,,
Address: 24001 VIA FABRICANTE
Phone: (949)830-1283
MISSION VIEJO, CA
Zip: 92691' 'License:- 735404
Arch - Eng: - -
Address: Address:
Phone: - Phone: -
Zip: License: License:
SCOPE OF PERMIT _
REMOVE OLD ROOF, INSTALL 1/2" OSB PLYWOOD,2 LAYERS 30 LB ASTM FELT, INSTALL PIONERR LIGHTWEIGHT
SHAKE TILE AND TILE TRIM.
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) 7545626
FEE SUMMARY
Plan Check:
$108.71 — Calc Valuation: $9,000.00
Permit:
$167.25 Claim Valuation: $9,000.00
SMIP Res:
$0.90
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total:
$276.86. -
-
_ 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) 7545626
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
FCar6er
e 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
Wfor which this permit is issued.
e and will maintain orkers'p om on insurance, s re uired by section 371X) of the Labor Code, for the performance of the work for which this permit is issued.
orkers' co - nsa on II`nsu_/��'I�ypanNTcCIe came and policy n b rbare: t
'v��'1� Policy Number. L9 — OZ — OW /S17
on need net a com leted It the permit is valued at one hundred dollars ($11X1) or lass.)
❑ I certify that in the performance of th ork for whic �I permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Californ nd a as that if I ' u d become subject to the workers' compensation provisions of Section 3 00 of th Labor Code, I shall forthwith
comply with these provision �/ 1,`�
Applicant Signature: Date: (�%} // U
WARNING: FAILURE TO SECURE WOR S' COMPENSA ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOU ARE ($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 un r, rovf p 9 (commencing with Section 7000) of Division 3 of the Business andPJofessions Coi and TA�'�jnse is in full
force and effect. Lic. # Class # �/ l�•�✓ /
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there i5 a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ 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 of her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers 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
pennit 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).
......................................................................................................................................................................................................................................................................................................................
........................ o r
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? [I 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 boos 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 [I 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
(It yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
....
............................................................................................................................................................................................................................................................................................................
7 It 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 Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. l agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signatur Of Le 0 er(s)fN to
r uthon Applicant 1.1 Date
CODE Ii. INSPECTION TYPE PAIS INITIAL CODE 0 INSPECTION TYPE 2&U ISL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final �y 208 Final Plumbing
200 Final Re-Root '-�2-,®L 16 210 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
'
PA
NOVV 10-77r15AID00 549 ***109.78
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 7200 COSTA MESA, CALIFORNIA 92626
APPLICATION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely — Use Ink Only
RECEIVED BV I DATE RECEIVED DATE ISSUED
BUILDING /�/�
ADDRESS Y
i es eve opmen orp.
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OWNER
P. O.
MAIL
BUILDING
ADDRESS 508 29th St.
ADDRESS
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Newgnrt Beach, Ca.
TRACT9866 LOT 28 BLOCK
CITY Nol�75-4'910
CONSTRUCTION
ALTER REPAIR MQVIP
LENDER
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BRANCH
Froperties West Development
OWNER
ADDRESS
VALUE
ARCHITECTOR ENGIN ERFran1L Spangler TE673-0952
s a $
ADDRESS 2240 Newport Blvd.,
FIRE
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Owner
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APPROVEDVUL DATE %lJ�
CONTRACTOR
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ADDRESS
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NO. OF USE O W
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STATE CITY
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SIZE NO. OF BLDGS
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FRONT FT. FT.
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USE OF
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Separate permits are required for
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electric, plumbing and heating work.
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USE OF BUILDING AND WORK TO BE PERFORMED
DISTANCE BET.
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1 hereby acknowledge that I haver this applic on and state
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that the above information Is correct and agree to comply with
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all laws regulating building construction, and I shall not employ
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any person in violation of the workman's compensation laws of
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the State of California.
3
I hereby certify that 1 am properly licensed as a contractor under
SQ. FT. 2,295
a
THE AMOUNT SHOWN UNDER VALUATION IS FOR
the State of California Business and Professions Code, Division 3,
m_
Chapter 9, and that such licenses are In full force and effect, or I
THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exempt from the provisions of the State of California Business
b
VALUATION
PERMIT FEE E
and Professions Codeplvision.3, Chapter 9.
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Signature of (—
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PLAN CHECK E105K0
Permittee A
$ 61 s lOO
TAX E 4.28
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TOTAL PAID E D
Authorized Agent v �