HomeMy WebLinkAbout892 CORTEZ ST - Building Permits, ' CITY OF COSTA MESA �
.
BI/ILDING DIV/SION
F � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www ci wsta-mesa.ea.us
�, FOR INSPECTIONS CALL: (714) 754•5626
��
PERMIT NUMBER: BC08-00274
PERMIT TYPE: B COMBO
Sub Type: RES_ALT
JOB ADDRESS: 892 CORTEZ ST CM
APN: 14732219 -
Vicinity: •
Const Type: V-B - SQ. Fi:
a
Zoning:R1, ,
414
STATUS: ISSUED
DATE ISSUED: 0710912008
ISSUED BY: YH
� �Suite/Unit:
Primary Occ: R3
Valuation: $48,253.60
SCOPE OF WORK: ADD 414 SF TO A SINGLE STORY SFD. WORK TO INCLUDE A NEW BEDROOM BATHROOM AND DEN.
REMODEL KITCHEN REMODEL CONVERT AN EXISTING BEDROOM TO BECOME A LAUNDRY ROOM.
MECH. - 3 DUCT EXTENSIONS & 1 VENT FAN.
ELECT. - 12 LIGHTS, 20 OUTLETS, 7-SWITCHES, 1 MTOR, 1 200 AMP SERVICE UPGRADE & RELOCATE & 1 SUBPANEL.
PLUMB. -1 DISHWASHER, 1 GAS OUTLET, 1 WASHER, 2 SHOWERS, 1 KITCHEN SINK & 1 TOILET. - � . ��
OWNER: VOGLER,NICHOLAS ' Address: 892 CORTEZ ST - Unit: ,,� 7�,
Phone: 949-476-9008 � City/State2ip: COSTA MESA, CA ��� •*
APPLICANT: CARTER, ED
Phone: 949 8884769 �
Address:
Ciry/State/zZip:
CONTRnCroR: EDWARD CARTER CONSTRUCTION INC License No. 707451
Phone: (949) 868.4769 . Address: 8 EASTRIDGEUnit:
Cell: , City/State: TRABUCO CANYON, CA
ARCHITECT:
ENGINEER: RASHEED, ZOHER
License No.
License No.58615
COMBINTATION PERMIT FEE SUMMARY
Building Plan Check: "' $412.20
Building Fees: �, $634.15
Electrical Fees: $132.15
Mechanical Fees: � $44.45�
Plumbing Fees: $98.25
SMIP Residential: $4.83
SMIP Commercial: $0.00
TOTAL FEES: $1,326.03
•'Rafar to (ee receipts for all f¢es paid for proje<t
Unit: :
ZipCode 92679 '
PHONE:
PHONE:626-912-3365
il .'��'G��.
:-, r � °� i s;
NOTICE: 7he work authorized by ihis pertnit shall comply with all applicable handicap access requirements under Califomia sWtutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. �
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply wiM all applicable codes, and all
required inspections and flnal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this De�it.
CODE/. ixsrEcnoxTrve o� inmu 4Q1J,�.� INSPELl10XTYPE p� x i
1818 Fixed System Final Fire Preven6on 208 Final Mechanical
1268 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electriwl
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire place 220 Final Planning Appmval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
WORKERS'COMPENSATION DECLARATOI� .
I hereDy a�rm urWer penalry of perjury one oi the tollowinq declaralions:
❑ I have and will maintain a certifica[e of consent to self-Insure for vrorkers'
compensation, as providetl for by section 3700 of the Labor CoCe, for the
peA�ance of the work for which this permit is issued.
Q I have antl will maintain workers' compensation insuranca, as required by
seclbn 3700 of ihe Labor Code, for the peRortnance of Ihe work for which ihis
permit is issued. My workers' compensation Insurance carner antl policy
number are: / / p
Cartier. �T `1'F��� / �/_�liC�� �%
(TlisseU n�wmpie�e�.alhe 4kvaM1retlatmenurMrcONears(Sf001aless.l
Policy Number: � � ��� ���7 �
❑ I certify lhat in Ihe peAO�ance of lhe work (or which lhis permit is
issuetl, I shall not employ any person in any manner so as to become subject
to the workers' compensation laws of Cali(omia, and agree Ihat it I should
become subject to Ihe worker5' compensation provisions of Section 3700 of
the Lab ode, I s II � hyw' i co�mply wi[h [h�ese provisions.
� ��1� 7-9 � �
Apphranl'S SignaWrE Date
WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CNIL FINES UP TO ONE HUNDRED iHOUSAND 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 licens¢d under provisions o( Chapter 9(commencing
with Section 7000) of Division 3 0! the Business and Prolessions Code, and
my license is in full force antl effecl.
Lic. # ��� �i � Class #
����� 7-�-�'
Con raclor's SgnaWrC Dale
CONSTRUCTION LENDING AGENCY:
❑ I hereby aKrtn that the�e is a construction lending agency for the
peRormance of Ihe work ta which this pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lentler's Address:
SignaWre Da�e
OWNER-BUILDER DECLARAYIONS:
I hereby affirm that under pen211y of perjury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LA�N for the following reason (Sec. 7031.5,
Business and Professions CodB: Any city or county which requires a pertnit to
consVuct, alter, improve, tlemolish, or repair any sWCWre, prior to its
issuance, also requires the applicant for such pertnil lo fle a signed stalement
Ihat he or she is licensed pursuant to the provisions of the Contractors
License Law (C�apter 9(commencing with Section 7000) of Division 3 of the
Business and Pro(essions Code) or [hat he or she is exempt therefrom and
the basis (or [he alleged exemp�ion. Any violation of Seclion 7031.5 by any
applicant for a permit subjects the applicant to a civil penalry of not more than
five huntlretl dollars ($500).):
❑ I, as owner o( Ihe property. or my employees vnth wages as their sole
wmpensation, WILL DO THE WORK, and the structure is not intendetl or
oKered for sale (Sec. 7044, Business and Professions Cotle: The Coniractors
License Law does not apply to an owner of property who builds or improves
thereon, and who does such work himself or herself or throug� his or her ovm
employees, provided that such improvements are not intentletl or offered tor
sale. If, however, the buildinq or improvement is sold within one year of
completion, the ovmer-builder vrill have the burden o! proving thal he or she
did not build or improve for purpose of sale.).
❑ I, �as owner of ihe property, am ERCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the pmject (Sec. 7044. Business and
Professbns Code: The cont2ctOrs License law dces nol apply to an owner of
propeAy who builds or improves lhereon, and who wntracls fw such prqect with
a contracta�s) license pursuant to the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for Ihis reason:
JOS)�46 (]N)�
/,
Owner ID veMed by A�xense. ❑ Yes ❑ No
Drivefs License No. 6cpires:
Verification of Ownership by (type o1 document, i.e. - property lax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ' '
❑ I hereby cetlAy ihat no ezcavalion (rve (5) or more feet in depth into wliich a
person is requiretl to descentl, wfll be made in conneclion with work aWhorized
by this pertnit, and that no building slmcture, scaffdding, falsevurk, a tlemolition
or dismantling Ihereof, will be more Ihan thirty-six (36) lee� high. (Chap. 32, Grp
2. M 2. Sec. 341. Trtle 8, Calitomia Atlministralive Cafe).
❑ As ovmer-builder, I will not employ anyone to do vrork which would
require a permit from the Division o( IndusMal Safety, as noted above, unless
such person has a pertnit lo tlo such work from the tlivision.
Appllcanl's SignaWre Dale
Division o( Industrial Safety Permit Number
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to file and
certity a Business Plan for emergency response to release or threatenetl
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the Califomia Health and Safery Code requires, with some
exceptions, [hal a Business Plan be fled wilh the Costa Mesa Fire
DepaAment by every business which has at any one lime dunng a reportetl
year a quantity of hazardous matenals equal to or greater Ihan a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic teet of compressed gas
at standard temperature and pressure).
2. Does or will the appliwnt or present or /uture building occupant need b file
a registration form for acutely hazardous matenals? ❑ Ves ❑ No
(Seclion 25533 of the Califomia Health and Satery Cotle, with some
exceptions, requires registration with the Costa Mesa Fire Depa�ment by
each business which at any one time has on hand a quantity of awtety
hazardous ma[erials equal lo or greater than a weight of 500 pountls, or a
volume of 55 gallons, or 200 cubic feet of compressed gas al standartl
temperature antl pressure).
3. Does or will the applicanl or present or fu[ure building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acu[ely
hazardous matenals)? ❑ Yes ❑ No
(Section 25534 of the Calitomia Health and Sa(ery Code provitles that the
Costa Mesa Fire Department may require the preparation, certificalion and
fling wilh Ihe Fire Depariment of an RMPP by businesses which are requiretl
to register awtely hazardous materials with the Fire Departmenl.
4. If an RMPP is presently required, has Section 25534 of the Califomia
Health and Safely Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or (uNre building occupaN require for
Ihe vrork which is the subject of Ihis application a permil br such construction
or modifcation from the South Coast Air Quality Management District or from
any other air pollution conlrol distnct or agency? ❑ Yes ❑ No
(Section 658502 of the Califomia Govemment Cotle requires ihat t�e requested
infortnation be fumished on applications for non-residential builtling pertnits�.
6. Will any patl of lhe faciliry to be constructed untler Ihis permit be within
1000 feet from lhe ouler boundanes of a school? ❑ Yes ❑ No
(If yes", Ihe lacility musl mee� Ihe requirement of Sections 25534 and 42303
o( the Califomia Health and Satety Cotle).
7. If a permit from lhe South Coast Air Qualiry Management District or other
air polWtion control district or agency is required for the work which is the
subjecl of Ihis applicalion, have all of the disclosures prescnbed by Califomia
Health antl Safety Code Seclion 42303 been made? ❑ Yes ❑ No
8. Qf yes', attach certificate of wmpliance from the appropriate air pollution
control officer). ' � � �
CERTIFICATE OF COMPLIANCE: I cenify�that under penalry o( perjury'�the
information given above is correcL I agree ro comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions. , ��
SignaWre Dale .
CERTIFICATE OF COMPl1ANCE ANO'AUTHORIZATION OF ENTRY: 1
certify under penalty of perjury that I have read Nis appliwtion and�state that
the intormation given is wrrecL I agree to comply wilti all state laws and city
ordinances relaGng to building construction, and authorize representatives o(
Ihe City of Costa Mesa to enter upon the above-described property for
inspeclion purposes. I agree not to occupy or allow occupancy o( any building
authorized by this permit until final inspection. �
S WreaiL �� ^ _pal�
1
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✓
And/orAW�on2¢CAPO��WnI DJte
DEPUTY 1 INSPECTI�.�� SE�RVICE IN� �
25121 DE SALLE ST, LAGUNA HILLS, CA 92653
1- 800 - DEPUTY 1= 1- 800 - 337 - 8891
ECIAL INSPECTION REPORT
,�
DEPT, OF BLDG. & SAFETY
CITY OF � z-�a �.�(�SA
COUNTY OF
C�; 7-�?-s� -��
Buifding Permit No.�� �g "�%0 2� i Job. No. Date �' ���0�
Jobindentification/Address V6b�� 2�5. , �%Z C.�✓Li'�zL Si • C-`Ni
General Contractor/Address 6_ j" Cv"r�.�s'r"- •
Sub - Contractor / Address --^
Structural Engineer/Address Arch:
REINFORCED CONCRETE MASONRY HI-TENSILE BOLTING CHEMICAL
PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE OTHER
All inspections based on a minimum ot 4 hours 8 over 4 hours • 8 hours
minimum. Any inspection ertending past the noon hourwill be billed as 8
hour minimum. In addition, any inspection extending past an 8 hour pe-
riod. or Saturday inspection will be billetl at time and a half.
ATTORNEY'S FEES - If any action at law or in equity is brought to enforce or interupt the terms of tlii§'Coritract, the prevailing party
shail be entitled to reasonable attorney's fees, costs and necessary disbursements in addition to any other relief to which such party maybe
entitled. „
SPECIAL INSPECTION REPORT
t-�4 � �9 �-� `'
Inspector's Name: Inspector's Signature: �
i.�. No. �� i 3 5`i� •� 9 has been filed and it states that the above work to the best of
provisions of the Uniform Building Code and meets approved plans and specifications�
Approved by:
Projeet Superintendent
/ -�
complies with the
Submitted,
- CITY OF COSTA MESA
BIIILDING DIVISION
77 FAIR DftIVE, COSTA MESA, CA 92626 • Q14) 754-5273 • Faz (714) 754-0856 • www.ci.costa-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626 ,
PERMIT NUMBER B08-00119
PERMIT TYPE B ROOF2 STATUS: ISSUED
APN: 14132219 � DATE ISSUED: 04/0912008
ISSUED BY: RMD
JOB ADDRESS: 892 CORTELST CM :' Suite/Unit:,:;
Vicinity: HOUSE AND GARAGE
Squares: 2400 , � ' � ' � � -. � Valuation: �- �� $9,780A�
SCOPE OF WORK: TEAR OFF�(E) ROOF��.MATERIALS, INSTALL 1 IAYER OF 30# FELT ON A:�4:14 PITCHED.ROOF AND REROOF
WITH 30 YEAR COMP SHINGLES-ON AN ATTACHED HOUSE AND GARAGE APPROX, 24 SQUARES.AND REROOF 2
SQUARES OF FLAT ROOF QMPATIOrCOVER WITH TORCH DOWN. REPAIR AND REPLACE SHEATHING AS NEEDED.
OWNER: HUEBNER, ROGER H TR.c �� - - Address: � 892 CORTEZ ST� �� � � Unit:
PHONE: -- .- City/State2ip: COSTA MESA, CA �. �
���. , , ; . . .
APPLICANT: NOLTE, FRED `" 1 _. ��' Address: 10812 LA�BATISTA �� „ . Unit:
PHONE: 714-964-0554 .� , City/State/Zip: FOUNTAIN VALLEY� .-� - �
3,�., � . . . , .. .. � . ... , - '
CONTRACTOR: NOLTE ROOFING �' . � � License No. ��418550
Address: 10812 LA BATISTAUnit: �- PHONE: 714-964-0554 --
CitylStatelZip: FOUNTAIN,VALLEY ' .92708�. , _ _ , _ CELC , �
ARCHITECT:
ENGINEER:
FEE SUMMARY
Reroof Plan Check:
Reroof Permit Fee:
Reinspection Fee:
TOTAL FEES
$o.00:
$15125
$0.00
$181.25
License No.
License No. � -
PHONE:
PHONE!
NOTICE: The work authori;ed by this permit shall comply with all applicable handicap access requirements under Califomia statutes and relaled
regulations. (Ord. No. 92-28, § 1, 12-21-92) .
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the ezpiretion of this permit.
CO�E/. INSPEC710NTYPE DAIE IN1fML COOEt, INSPECPONTYPE O�jF� INTRULS
7616 Fized System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final . A' 208 Final Plumbing
20o Final Re-Roof �� 'B V� 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Faclory Fire Place 220 Final Planning Approval
203 FinalSign 222 FinalSi�e
204 Final Demolition 250 FinalBuilding/OCcupancy
;
� .
WORKERS' COMPENSATION DECLARATIOI
I hereby aHirm un0er penally of perjury one of the wllowing tleclarations:
❑ I have and will maintain a certificate of wnsent to self-Insure for workers'
compensation, as provided for by section 3700 of the Labor Code, for the
pertormance o( the work for which this permit is issued.
❑ I have and will maintain workers' compensation insu2nce, as required by
sectbn 3700 of lhe Labor Cotle. fw Ihe peAormance of the work tor which this
permit is issued. My workers' compensalion Insurance carner antl policy
number are: ��T� -�^ �„�
Camer._ � / j�U' Y
(TMa seIXm neetl/m�1/f Ee'cn/m-d7e��/ d/(he peim4 a valve0 el one hurMietl tldlars (5100) a less )
Policy�Number (�V 7 LY ��
❑ I ceAify Ihat in the peAormance of the work tor which this permit is
issued, I shall not employ any person in any manner so as to become subject
to lhe vrorkers' compensation laws of California, and agree that if I should
become s �ect to Ihe workers' compensation provisions of Section 3700 of
lhe Lab o e. I hall forthwith comply with ihese provisio s.
iAppliwnl's Signature ' ate
V ` ��
ARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLIARS
(5100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I �ere�y affrm that I am licensed under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of the Business antl Professions Code, antl
my license is in !fuKll force antl eHect. �
�Lic: #— �" � D .� � Class # �l
�`Cadtractor's5ignaWre �are - .
ONSTRUCTION IENDING AGENCY:
❑ I hereby aN'vm lhat lhere is a constmction lentling agency fw the
peAormance of the work for wfiich Ihis permit is issued. (Sec. 3097, Civil Code�.
Lender's Name:
Lender's Adtlress:
OWNER-BUILDER DECLARATIONS:
I hereby aKrm Ihat under penalty of perjury that I am EXEMPT FROM 7HE
CONTRACTORS LICENSE LAW for the (ollowing reason (Sec. 7031.5,
Business antl Protessions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to ils
issuance, also requires the applicant tor such permit to file a signed slatement
that he or she i5 licen5ed pur5uant b the provi5i0n5 of the COntraG[ors
License Law (Chapter 9(commencing with Section 7000) of Division 3 of ihe
Business and Professions Cotle) or t�at he or she is ezempt therefrom antl
the ba5is (or Ihe alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalry o( not more than
fve hundred dollars ($500).):
❑ I, as owner of ihe 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 tloes 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, provitled thal� such improvements are not intended or offered for
sale. If, however, the builtling or improvement is sold vrithin one year of
completion, the ovmer-builder will hava the burden of provinq that he or she
did not build or improve (or purpose of sale.).
❑ I, as ovmer of Ihe property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CON7RACTORS to construct Ihe projecl (Sec. 7044, Business and
Pmlessbns Code: The conl2ctors License Law dces not apply to an amer of
propeAy who builds or improves Ihereon, and who contracls fw such project vrith
a cmtracta(s) license pursuant to the Contractors license Lava.).
❑ I am exempt under sec. �
Business and Pmfessions Cotle for this reason:
905]-46 (3I0�)
Owner ID verifetl by dn lici ❑ Ves ❑ No � ,
. �
Driver's License No. Expires:
Venfication ot Ovmership by (rype of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: . �
❑ I hereby cetlHy that no ezcavation frve (5) or more feet in depth into which a
person is requiretl to descend, will be made in connection with work authorized
by this permil, antl tha� no building sWCNre, 5caffdding, falsework, or demWition
or dismantling thereof. will be more ihan thirty-sin (36) feet high. (Chap. 32, Grp
2, Art 2, Sec. 341, Title 8, Califomia Admini5l2We Code).
❑ As ovmer-builtler, I will not employ anyone to do work which v.ould
require a permil from the Division of Industrial Safery, as noted above, unless
such person has a permil lo tlo such work from the tlivision.
Appliwnfs SignaWre Date
Division o( IndusMal Safely Permi� Number: _ _
HAZARDOUS MATERIA�S AND EMISSIONS CERTIFICATION:
7. Will the applicant or presenf or tuNre building occupant need to fle antl
certify a Business Plan for emergency response to release or Ihreatened
release ofa hazardous material? ❑ Ves ❑ No
(Section 25505 of the Califomia Health and Sa(ety Code requires, with some
ezceptions, that a Business Plan be filed with the Costa Mesa Fire
Departmenl by every business which has a[ 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 (eet of campressed gas
at standartl temperature ana pressure).
2. Does or will the applicant or presen� or (uture building occupant neetl to file
a regislration form for acutely hazardous malerials? ❑ Yes � No
(Section 25533 of the Califomia Health antl Safery Cotle, wi[h some
exceptions, requires registration with ihe Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
hazardous materials equal to or grealer than a weight o( 500 pounds, or a
volume of 55 gallons. or 200 cubic feet o! compressetl gas at stantlartl
temperature and pressure).
3. Does or will the appliwnt or presene or fuWre building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)� ❑ Yes ❑ No
(Section 25534 of the Calilomia Health and Safety Cotle pmvides that Ihe
Costa Mesa Fire Department may require the preparation, certification and
fling with the Fire Deparlment of an RMPP by businesses which are required
to register acutey hazardous materials vnth the Fire Department.
4. If an RMPP is presently required, has Section 25534 of the Cali(omia
Health and Safely Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or fuNre building occupant require for
lhe work which is Ne subject of Ihis applicalion a permit for such construclion
or modificalion from Ihe South Coast Air �uality Management DisVict or from
any other air pollution control district or agency? ❑ Yes ❑ No
(Section 658502 of the Califomia Govemment Code requires lhat [he requested
infortnation be fumished on applications fv nomresitlential building permits).
6. Will any part of the facility to be constructed under this permit be vnthin
1000 (eet from the outer boundaries of a school? ❑ Yes � No
(If "yes", Ihe facility must meet Ihe requirement of Sections 25534 and 42303
of the Calilornia Health and Safery Code).
Z If a permil from the South Coast Air Quality Management District or other
air polWtion control district or agency is required for the work which is the
subject of this application, have all of the discbsures prescnbed by Califomia
Health and Satety Cotle Seclion 42303 been made? ❑ Yes ❑ No
8. (If'j�es", attach certificate of compliance from the appropriate air polWtion
conlrol officer).
CERTIFICATE OF COMPLIANCE: I certify Nat under penalry of perjury ihe
information given above is cortect. I agree to comply with all state laws antl
city ortlinances regarding Hazardous Matenals antl Emissions. �
Signamre Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF EN7RY: I
certify under penalty of pery'ury that I have read this application and state that
the intormation given is correcl I agree to comply with all state laws and ciry
ordinances relaling to building construction, and authonze representatives of
the Ciry ot Costa Mesa to enter upon the above-tlescribed pioperty for
inspection purposes. I agree not to occupy or allow occupancy of any builtling
authorized by thi ermit until final inspection.
Wr ,910wner�s) D e
� vS
;�An /o AWhorizetlApplicanl ��—'Dale
e,n �1e-r
OWNER
� GENERAL CONTRACTOR S
�AP No. ltF1'3'�' -1� LOT
,, INSPECTIONS
OCCUPANCY
'ORM BU4 � SM -
�ATE 7-i6-62
3UILDING P�RMIT NO.
VALUE
TRACT PIRF. ZONG DESCRIPTION OF WORK
Signaturel DATE I GROUP T TYPP
SUI3CONTRACTOR
7.ONE
Y
17559
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 9f7 COBTA MHBA. GALIFORNIA
For Applicanf to Fill In Complefiely
TYPE OR PRINT
BUILDING %�
ADDRH86 O K, C Z
COSTA MESA. CALIFORNIA
� ARGHITEGT
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DESCRIPTION OF WORK
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COVERING GOVERING
USE OF BUILDINC AND WORK TO BE PERFORMED
BUILDING
FE RECEIVED
JUL 16 1362
FINANCE OEF'I.
APPLICATION'POR ��R�SI�TA MESA
BUILDING
For Offiee Use Only
R8C81PT NO. P[flWLNp'_
COSTA MESA. CALIFORNIA
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'COSTA MESA BUILDING-SAFETY DEPARTMENT (INNNCE DEPT.
P. o. aox s�� COBTA MHBA. CALIRORNIA PLA�II f3'��� GOSTA MESA
La t y�,
Fo� Applicant fo Fill In Compleiely APPLICATION FOR PERMIT
TYPE OR PRINT
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ADDRESS 892 Coitez Stteet
COSYA MESA. CALIFORNIA FOf Of}IC@ USB OIII�/
FECEIPT NO. P[RMIT NO.
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DESCRIPTION OF WORK r dd
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TMAT 1 HAVH HWD TH18/� PP4GTION' TNE AMOUNT BXOWN UNDER VALIIATION IB FOR TX!
)VE IB CORRHGT �NO AGJtEE TO COY- pURP086 OF EBTABL18HtNG A PERMIT vEE ONiY.
VANC89 AND �ATE LAW6 aeauunxa
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