HomeMy WebLinkAbout1075 CORONA LN - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address:
1075 CORONA LN
FEE SUMMARY
Status: ISSUED
Suite No
Quantity
_.
Applied: 08/03/2001
Vicinity:
$23.50
Temp Dist System / Lighting
Issued: 08/03/2001
Parcel Nunmber:
14162427
Busway /100 It
$0.00 0
Res. a/c package
$0.00
Standing Section
ISSUED BY:
Applicant:
MAGNUSEN, DAVID A
0
Misc Electrical Equipment
$0.00 0
Address:
1075 CORONA LN
0
Transformers up to 1 kva/kw
$0.00 0
Pool / Spa
$49.50
Phone:
714-751-1056
$0.00 0
Lighting Fixts
COSTA MESA, CA
Zip:
92626
$0.00 0
owner:
MAGNUSEN, DAVID A
0
.................up to 100 kva/kw
$0.00 0
Address
1075 CORONA LN
0
..................over 100 kva/kw
$0.00 0
Non Res Appl
$0.00
Phone:
714-751-1056
$0.00 0
Res Appl
COSTA MESA, CA
Zip:
92626
$0.00 0
Contractor:
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
REF 601-01208. FOR POOL AND SPA.
COMMENTS f SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
2"646 (SM)
FEE SUMMARY
Quantity
_.
Quantity
ISSUE FEE
$23.50
Temp Dist System / 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
$0.00 0
New Res (3+units)
$0.00
0
Transformers up to 1 kva/kw
$0.00 0
Pool / Spa
$49.50
1
................ up to 10 kva/kw
$0.00 0
Lighting Fixts
$0.00
0
.................up to 50 kva/kw
$0.00 0
Recept Outlets
$0.00
0
.................up to 100 kva/kw
$0.00 0
Switches
$0.00
0
..................over 100 kva/kw
$0.00 0
Non Res Appl
$0.00
0
Low Voltage Equipment
$0.00 0
Res Appl
$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 100hp
$0.00
0
Other Electrical Fee
$0.00
Molars over 100hp
$0.00
0
Communication drops
$0.00
0
Investigation Fee
$0.00
Sub panel to 200a
$0.00
0
Plan Check Fee
$0.00
Pole Light Pkg
$0.00
0
Reinspection Fee
$0.00
Sign Circuits
S0.00
0
Temp Pwr Pole
50.00
0
TOTAL CALCULATED FEES
$73.00
Intermed Pole
$0.00
0
COMMENTS f SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
2"646 (SM)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is Issued.
❑ I have and will maintain workers' cadon Insurance, as required by section 3700 of the Labor Coda, for the performance of the work for which this permit Is Issued.
My workers' wmpensatlon Insuranceante carder and policy number are:
Cartier: Polity Number:
(This section need not be completed if the permit is valued at one hundred dollars ($100) or less.)
❑ I certity that In the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING: FAILURE TO SECURE WORKERS' OOMPENSATICN COVERAGE IS UNLAWFUL AND SCULL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLIARE ($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 Professlons Code, and my license is In full
force and effect. Lic. a Class M
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 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 pemlit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
S-1.5—nor 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 Cade: 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
Id 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, es owner of t property, am EXQLUSIVELY CgNTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The Licensec(Lda� does not app to an owner of property who builds or improves thereon, and who contracts for such project with a contractors)
icense pur o the Contra rs License Laws.).
❑- I:am empt unde Business and Professions Code for this reason:
r
'Signature: _�-Date: �a
i
Owner ID V dffe drive liven ❑Yes ❑ No Dnvers.LJcanse jExpires:
Verification of Ownership by (type of tloiument, Le. - property tax bill or dead):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2. Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then 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 thea licant or resent or future building occupant need to file a registration form for acute) hazardous materials? V
........t f.. .... .....
pp p g p g y❑ es
(Section 25533 of the California Health and Safety Code, with some excepflons, 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 appplicant 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, codification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
...................................In...................................................................................................................................................................................................................................................................................................................................................
4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
............................................................................................................................................................................................................................................................................................................................................................................................
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this plication aPermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Byes a 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 feclli fy 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? ❑ Yes ❑ No
..._...................._....................... ____............................___.._..............._... _............................__...........................__..........................._....................................__..__.._............................._................___.............._.................
_..
8 (If yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE 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 complyItlfalTSt@to laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described prop. or ins ecb n pur ow. agree not to occupy or allow occupancy of any building authorized by this ponniiitt u II final inspection.
11f4' oilq-4 2/
re f galO(s) y Date
a
And/or Authorized Applicant Date
CODEC INSPECTION TYPE BATE INTITA CODES INSPECTION TYPE 2AM 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/Retaming 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 BuildingrOccupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
PLUMBING PERMIT
Job Address:
1075 CORONA LN
Status:
ISSUED
Suite No
Applied:
08/03/2001
Issued:
08/03/2001
Vicinity:
ISSUED BY:
Parcel Nunmber.
14162427
Applicant:
MAGNUSEN, DAVID A
Address:
1075 CORONA LN
'
Phone: 714-751-1056
COSTA MESA, CA
Zip: 92626
Owner:
MAGNUSEN, DAVID A
Address
1075 CORONA LN
Phone: 714-751-1056
COSTA MESA, CA
Zip: 92626
Contractor:
Address:
Phone:
Zip:
License:
Arch / Eng
Address:
Phone:
Zip:
License: .
SCOPE OF PERMIT
REF BOt-01208. FOR POOL AND SPA.
1 HEATER.
1 POOL AND SPA.
FEE SUMMARY
AMT QTY
AMT
QTY
AMT
QTY
ISSUE FEE
$23.50
Laundry Tub /Washer
$0.00
0
Sump Pump
$0.00
0
Backflow irrigation
$0.00 0
Landscape Irrigation
$0.00
0
Swimming Pool
$60.75
1
Backflow Preventer
$0.00 0
P -Trap
$0.00
0
Trap Primer
$0.00
0
Bathtub
$0.00 0
Pressure Regulator
$0.00
0
Urinal
$0.00
0
Clarifier System
$0.00 0
Process Piping (per 10 it)
$0.00
0
Vacuum Brkr Bkflow(1-4)
$0.00
0
Connect (Ice,Soda,etc)
$0.00 0
Receptors
$0.00
0
Vacuum Brkr Bkflow(5+)
$0.00
0
Dental Units
$0.00 0
Septic Tank
$0.00
0
Wash Basin
$0.00
0
Dishwasher
$0.00 0
Sewer Cap for Demo
$0.00
0
Wash Basin Set
$0.00
0
Drain, Floor
$0.00 0
Sewer Connect
$0.00
0
Waste and Vent System
$0.00
0
Drain, Rainwater
$0.00 0
Sewer Private Line
$0.00
0
Water Closet (Toilet)
$0.00
0
Drain, Roof
$0.00 0
Shower
$0.00
0
Water Heater / vent
$0.00
0
Drinking Fountain
$0.00 0
Sink, bar
$0.00
0
Water Piping (Inst or Rep.)
$0.00
0
Expansion Tank
$0.00 0
Sink, commercial
$0.00
0
Water Re -pipe
$0.00
0
Gas Earthquake Valve
$0.00 0
Sink, Floor
$0.00
0
Water Service
$0.00
0
Gas (1-4 outlets)
$0.00 0
Sink, kitchen
$0.00
0
Water Softener
$0.00
0
Gas (Over 4 outlets)
$0.00 0
Sink, service/mop
$0.00
0
OTHER
$0.00
Gas Repipe
$0.00 0
Spa (private)
$30.25
1
VIOLATION
$0.00
Gas Service
$0.00 0
Spa (public)
$0.00
0
PLAN CHECK r/
$0.00
Interceptors (Grease, Oil)
$0.00 0
REINSPECTION
$0.00
0
Interceptors (Sand Auto ) $0.00 0
TOTAL CALCULATED FEES:
$114.50
NOTICE: The work authorized by this permit
regulations. (Ord. No. 92-28, § 1, 12-21-92)
is under California statutes and related
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) 754.6626
244&491600)
L
DECLARATIOMS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit Is Issued.
❑ I have and will maintain workers' compensation Insurance, as required by secflon 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: Policy Number:
(This section need not be completed it the permit is valued at one hundred dollere ($100) or less.)
❑ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers'
compensation laws of California. and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: Data:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML 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 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
force and effect. Lic. A Class M
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code).
Lender's Name: 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, pflor 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 Sectlon 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than eve hundred dollars ($500).):
/❑� I, es 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
AM of
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.).
►^� n o1 property, em EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The tractors 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 pu a to the Contractors License Laws.).
❑ I am a pt u der Business and Professions Code for this reason:
/Signature: Date:
Owner ID van — y drtvers li ❑ Yes ❑ No Drivers License No. --Expire5�
Verification of Ownership by ( ell, document,, I:e.'- property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certity that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made In connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
..............................................................................................................................................................................................................................................................................................................._.......................................................................
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
............................................................................................................................................................................................................................................................................................................................................................................................
3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
................ ... ................ ........................................................................................................................................................................ _............................_............................................................_........... ............................................ _...........__.......
4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No
............................................................................................................................................................................................................................................................................................................................................................................................
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apermit 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 65050.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
............................................................................................................................................................................................................................................................................................................................................................................................
6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
............................................................................................................................................................................................................................................................................................................................................................................. _.............
7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of me disclosures prescribed by California Health and Safety Cade Section 42303 been made? ❑ Yes ❑ No
......_.................___...........................-_._._._....................................................___.................._._....................___....................__..........................................................._—___.....__.__............. _............. _........ _
8 (II 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: Data:
CERTIFICATE OF COMPLIANCE AND AUTHORIZAT10N 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 corn a all state laws end city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described pr rty for in action s. I agree not to occupy or allow occupancy of any building authorized by this permit unyl fin9l inspection.
//iAe
/ignatur Of 1_77
e nor(s) Date
AndiOr Authorized Applicant Date
800E t. INSPECTION TYPETYPE 2M RIDDALS COo1:E INSPECTIONTYPE g,,g INTITIA16
1616 Fixed System Final Fire Prevention 206 Final Mechanical `
1266 Pool Spa Final 208 Fidel Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final BuildingJOccupancy
Job Address:
1075 CORONA LN
Suite No
Inst FAU <100 k BTU
Vicinity:
-0
Parcel Number:
14162427
Applicant:
MAGNUSEN, DAVID A
Address:
1075 CORONA LN
Inst / Rep. Recess Wall Hlr
COSTA MESA, CA
Owner:
MAGNUSEN, DAVID A
Address:
1075 CORONA LN
Refrig Sys >I00 k BTU
COSTA MESA, CA
Contractor:
Gas Piping
Address:
0
MECHANICAL PERMIT
Phone: 714-751-1056
Zip: 92626
Phone: 714-751-1056
Zip: 92626
Phone:
Zip:
License:
SCOPE OF PERMIT
REF B01-01208. FOR POOL AND SPA.
1 HEATER. -
Quantity
ISSUE FEE
$23.50
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 Hlr
$0.00
0
Refrig Sys <I00 k BTU
$0.00
0
Refrig Sys >I00 k BTU
$0.00
0
Gas Piping
$0.00
0
Factory Fireplace
$0.00
0
Hood w/Mech Exhaust
$0.00
0
VAV Box
$0.00
0
Vent Fan / Single Duct
$0.00
0
Appliance
$10.65
1
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: 08/03/2001
Issued: 08/03/2001
ISSUED BY:
VV
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/ 100k BTU
$0.00
0
3 To 15 hp 1500 k 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 hp
$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
TOTAL CALCULATED FEES $34.15 n
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Californiastatutesand 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
2446-48 (fiW)
J
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit Is issued.
❑ 1 have and will maintain workers' compensatbn 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 carver 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.)
❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML PINES UP TO ONE HUNDRED
THOUSAND DOL ARE ($100,ODO). 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 llconsed 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. k 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: 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 girl Professlons 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
s, bje the applicant to a civil penalty of not more than five hundred dollars ($500).):
10 or— 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
sowithin one year of completion, t 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, a EX USIVELY CONTRACTING WITH LICENUD CONTRACTORS (¢E:onsuuct the project (Sec. 7044, Business and Professions
j
Code: The contractors License tloes not apply to an owner of properMuIlds or Improves thereon, and who contracts for such project with a contractors)
license pursuant to the Contr c iLicense Laws.).
❑ 1 am exe nd sec Business and Professions Code for this reason:
Signetur� � Date: ei
Owner ID verified by drivers ansa. ❑ Yes
es❑ No Drivers License No.
'Verification of Ownership by (type of ument, Le. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 4�
❑ 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, falsawork, 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 e
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 ar future bulltling occupant need to file a registration forth for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safely Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
............................................................................................................................................................................................................................................................................................................................................................................................
3 Does or will theappplicant 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? ❑ Yes ❑ No
............................... ........... ............................................ _.............................................. ................................. ............................... ................ ............. ...................................................................................................................... ................. ..................
5 Doas or will the applicant or present or future building occupant require for the work which is the subject of this application aadmit for such construction or modification
from the South Coast Ali Quality Management District or from any other air pollution control district or agency?Yes 8 No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
............................................................................................................................................................................................................................................................................................................................................................................................
6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
....................................................................................................................................................................................................................................................................................................._.............._................................................................_..
7 If apermit from the South Coast Air Quell ry Management Distinct or other air pollution control district or agency Is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
...............................__......................... _........._....................... ..............................._._..................._.......................__......................_.._........................._............__..........................._..........._............
_
8 (If yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I cadity 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
cored. I agree to corn nh state cos end city ordinances relating to building construction, and authorize representatives of the Clry of Costa Mese to enter upon the
above-described pro try for insp ctio as. I agree not to occupy or allow occupancy of any building authorized by this permit yntil f al inspection.
aq
P3/
Ignatu Of L_ wnar(s)s �Tte
And/Or Authorized Applicant Date
CODE 1. INSPECTION TYPE INTITIALa CODE INSPECTION TYPE 2AR 7...NTITIAr
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
1
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.qB.6RLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 1075 CORONA LN
Suite:
Vicinity: RESIDENCE AND ATTACHED GARAGE
Parcel Number: 14162427 Zoning:
Applicant: COFFEY, BRIAN
Address: 2428 NEWPORT BLVD
UNIT 5 Phone: (949) 722-8846
COSTA MESA, CA Zip: 92672
Owner: MAGNUSEN, DAVID A
Address 1075 CORONA LN
Phone: 714-751-1056
COSTA MESA, CA Zip: 92626
Contractor:
THE ROOFING SPECIALISTS
Address:
2428 NEWPORT BLVD
Issued:
UNIT 5 Phone: (949) 722-8846
$0.54
COSTA MESA,CA
Zip:
92672 License: 734068
Arch :
Address:
Phone:
Eng:
Address:
ISSUED BY:
Status:
ISSUED
Applied:
10/17/2003
Issued:
10/17/2003
Phone:
Zip: License: License:
SCOPE OF PERMIT
TEAR OFF EXISTING WOOD SHAKE, INSTALL SOLID SHEATHING, FELT, AND COVER WITH 30 YEAR COMP. INCLUDES ATTACHED
GARAGE.
Plan Check:
$0.00
Permit:
$125.25
SMTP Res:
$0.54
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total: $125.79
SETBACKS
MAIN STRUCTURE Front 0-0
ACCESSORY Front 0-0
PARKING Existing: 0
FEE SUMMARY
PLANNING & ZONING
Rear 0-0 Left 0-0
Rear 0-0 Left 0-0
Required: 0 Proposed: 0
Calc Valuation:
Claim Valuation:
Right 0-0
Right 0-0
$5,365.00
$5,365.00
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
2"646 (droo)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
kI 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
for which this permit is Issued.
e and will maintain workers'compensation insuranceas required bysection 3700 of fife LaborCode, far the performance of the work for which this permit is Issued.
orkerss'/'com nsa�ti n Insur lice r'er antl policy number ere: ) 9/�%QC! J , ATI 7U Policy Number: / 2 C C U / a�
(This section need not be Completed if the pe it is valued at one hundred dollars ($100) or less)
❑ I certify that in the performance of the worifor 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 Cali mia, and gr that if I should become subject to the workers' compensation provisions of S/,ecti n 3700 of the Labor Code, I shall forthwith
comply with these pro Y to . c V
Applicant Signature: Date: / /
WARNING: FAILURE TO SECUR ORKERS' AP SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOUARE($100,000), IN ADDri O ECOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND AT
FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licans u de PPjjo ' ions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professl0 s Code, and my license is in full
force and effect. Lic. 8 V i9 Class q
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 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 contractor(s)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation live (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
................................................................................................................... ................................................................................................................................................................................. .......................................................................................
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet at
compressed gas at standard ............................... temperature antl pressure).
..................._........................___................................................ ____................ ............. _................................ _............................. _.............................. __............................. _....................... _............. _.............. _............
3 Does or will the Nappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ o
Rection 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
partment 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? ❑ 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 eppemit 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).
..............................................................................................................................................it'b"........ithi........................................................'b"o,....................................................................................,.......................................................................
6 Will any pen of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Ves ❑ No
(If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
...........................................................................................................................................................................................................................................................................................................................................................................................
7 If a Permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which Is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
.................................................................................... ...................................................................... -.-.... ..............................._.................................... __................................................................................................................... .......................... ..
8 (If yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZAT10N OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
nature Of Legal Owner(s) /61
6 AY--f Date
.d/Or Authorized Applicant Date
CODE r. INSPECTION TYPE 2ATE Ifs CODE r MSPECt10N TYPE geTF iNTn3ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final f 208 Final Electrical
200 Final Re-Roof !�L � 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 BuildingJOccupancy
e
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, GA 92625
BUILDING PERMIT
Job Address: 1075 CORONA LN
Suite:
Vicinity:
Parcel Number:
14162427
Zoning:
Applicant:
MAGNUSEN, DAVID A
$251.25
Address:
1075 CORONA LN
SMIP Res:
$1.50
Phone: 714-751-1056
SMIP Com:
COSTA MESA, CA
Zip: 92626
Owner:
MAGNUSEN, DAVID A
$0.00
Address
1075 CORONA, LN -
Inspection:
$0.00
Phone:
Total:
COSTA MESA, CA
Zip: 92626
Contractor:
Address:
Phone:
Zip: License:
Arch
Address:
Eng:
Address:
Status: ISSUED
Applied: 08/03/2001
I ssssued: 08/03/2001
ISSUED BY:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
CONSTRUCT INGROUND GUNITE POOL AND SPA, SEE ATTACHED POOL STATE CODE REQUIREMENTS.
FEESUMMARY
Plan Check:
$163.31
Calc Valuation: $15,000.00
Permit:
$251.25
Claim Valuation: $15,000.00
SMIP Res:
$1.50
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total:
$416.06
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE
Front 0-0 -
Rear 0-0 Left 0-0
Right 0-0
ACCESSORY
Front 0-0
Rear 0-0 Left 0-0
Right 0-0
PARKING
Existing: 0
Required: 0 Proposed: 0
NOTES:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
iu-Muciej
G
Z
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workerscompensation, as provided for by section 3700 of the Labor Cole, for the performance of the
work for which this permit Is issued.
r
ElI have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which thisr permit is Issued.
My workers' compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not he completed if the pemlit is valued at one hundred dollen ($100) or less.)
❑ 1 mnihy that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
Comply with these provisions.
Applicant Signature: Date:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED
THOUSAND DOLURE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 370fi OF THE LABOR CODE, 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
force and effect. LIC. # Class #
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lenders 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
Byslnew 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
$Objects 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.
044, 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 the pro am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to conslmcL",projecP(Sec 7044-Business`and Professions
Code: The entree al nseJAQ-'fifes noeplply o an wrer`t�p�roperty v�bods-bLjjppno�'Ihe5Taa sand who contracts for such project with a contractor(s)
license pur cant the Cbnbactor5 LJC0rie8° wa.).
❑/Iem ex r s Business and Professions Code for this reason:
-Signature:
Owner ID verif y dove licens . ❑ Yes ❑ No Driver .Licdnse No. -
Expires:
a /i neo
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, Tifle 8, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
............................................................................................................................................................................................................................_....................................-.................................................-............................................................._....
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Califomia Health and Safety Code, with some exceptons, 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 Califomia 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
............................................................ ...................... .... ................................... ..... ........................... ....... ..................... .................................. ..... ............................................................................. .... ........ ............................................... I.,....................
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apermif 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 01 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? El Yes ❑ No
(It 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 Califomla Health and Safety Coda Section 42303 been mado7 ❑ Yes ❑ No
...................................................................................................................................................................................................................._.....................................................................................................................................................................
8 (If yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE 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 tete laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property f Inspec ion p o I agree occupy or allow occupancy of any building authorized by this per tun' final inspection.
%3%i
ature Legal 'O (s)--DeteJ
And/Or Authorized Applicant Date
CODE C INSPECTIONTYPE QAT): INTITACODE# INSPECTION TYPE MH INTMALS
1616 Fixed System Final Fire Prevention � 206 Final Mechanical
1266 Pool Spa Final '-Z+� 'L� l l ]C� 208 Final Plumbing
200 Final Re -Roof 210 Final Electrical
201 Final Bleck/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
2.0-250
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 317 COSTA MESA. CALIFORNIA
MAIL
For Applicant to Fill In Completely
TYPE OR PRINT
COSTA MESA, CALIFORNIA
I v IN.1
FROM
EFT 61 1 RIGHT
DESCRIPTION OF WORK
SIZE IX1
EXTERIOR WALL
garage.
ROOF
3
Shake
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IB CORRECT AND AORSE TO COM.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
BUILDING CONSTRUCTION.
SIGNATUREOF it- .,,,,_ v _11..
•
AUTHORIZED
FEE RECEIVED
U%2 5 1967
APPLICATION FOR PERMIT
FINANOPOWK
CIT1FO6F0j,A ,sVjE6 1/
RECEIPT NO.
:71M
PW1JCTTEV963
R
DATV CZErv�
LL.•
�l7
BUILDING
ADDRESS
FIRM
ZONE TYPE GROU
APPROVED
BY DATE
ZONING
2011[
NO. OF
USE OF NHW
R_1
PLANE 2
BDILDINOW att gar.
`E°A` Lot Tract 5023
DSSDRIPTIDN 1
A. P. NO. none
NOTE: NO EAV E OVERHANG SHALL BE LESS THAN
90' TO SIDE 8 REAR P. L.
EAVES
ALLOWED (U. B. C. REQUIREMENT)
YARDS APPROVED
YARDS APPROVED
MAIN BUILDING
ACCESSORY BUILDING
(FROM C L BEET)
FRONT �/ FT.
FT.
R. SIDE FT.
FT.
L. SID FT.
FT.
REAR !SPT.
FT.
DISTANCE BHT.
BET. MAIN Q
MAIN BLDGS.
ACCESS. BLDGS.
VAR.*
DATE
C.U.P.#
APPROVED
APPROVED 1,1 D.
L.
H-22-6
Dwell-in 226mv
Garage 460 S.F.
SQ. FT.
THEAMOUNT SHOWN UNDER VALUATION IS FOR THE
PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
VALUATION
PERMIT FEE S / J
5 23,925.00
PL'AN CHECK 5
TOTAL. FEE I
L05TA m�sA
SPECIAL INSPECT OH 13EGISTRATI ON
Address _I_ /C/wy. `--- — -----------..
:Hence Address—_r YL!t_
Numher & Street
Cav
story-TlfIINTNG _._._..
33 10 41,G PART tuA 1/.4 o,t! a9CG� _ 08'06 _.--
ess -- — �.
Street Gtv -��c-- V IP
icenses listed below must be currently valid and legible copy(s) and must be attached to this registratiol•.
DISCIPLINE
L.A. COUNTY
L.A. CITY
ORANGE COUNTY
OT"F-
---CONCRETE —
-
---�V
xCNdFf
DUGTILE MOMENT
RESIs TING FRAMC
-geSTTAE_S s_ING STEEL
wLI.DINO
10.w STAEN6TH BOLTING
--STRUCTURAL~�_
-- --_
-------w
MASONRY—
::INfORCEO GYPSUM
CONCRCTS
-'--
''.W&.ATI NO CONCRETE
-
-__—__
--
FILL
jPAAYEO ON GIBE
Pq OOGING
_
'.•NGS, OR LLLED PIERS.
CAISSONS
l
+CANOR FILLING
SPECIAL CASES
C
UNUSUAL HAZARDS
I hereby certify that I am qualified by training and experience to perform the inspections for which I hold
Shove listed Special Inspectors licenses, and will provide all certifications required by the City of Costa Mesa.
.,,N inspect and certify the following procedures:
I-=- )0 o L NA S�f� _ 9 T 711 Reade- y:D PPeEsS
,L'6^T Ta Fejta�-—....--
MMA'
i will certify not only to the job conditions but that they are in conlnrmance with the approved plan :t at
Iime, progress occurs on the above mentioned job relating to my areaisl of responsibility, without my Howl
or approval, I will stop the jobs progress immediately with notification i writing to the job superinte:.dent
notify the Building Division of the situation. A record o y sts d r inspections as agreed to above will
I .jaailable upon request by the Building Division, Upon qu I w' 's iit a complete package of testi:aand
.:,(,tion results. A letter certifying satisfactory Com 'o ill pr 'ded by me upon completion.
AVT54 . ?, -Z k - d
natur Date
= egistration is accepted and approved by:
CneeR Engineerl
ficiall
(Date)
CM/ 1060-46 Whit.- 6.4166 9 Olvilionl can.ry. sp.cbi �mo¢IP r: PMY - n....�....
I0'd 6660 ELL bil lI t133N rt H3HM 31ILIM