HomeMy WebLinkAbout1116 DANA DR - Building Permits(714) 754.5273 • Fax (714) 754-4856 • www.cf.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 1116 DANA DR
Suite No
Vicinity:
Parcel Number: 41207414
Applicant: ALLEN, MARK
Address: 7600 GARDEN GROVE BL
WESTMINSTER, CA
Owner: FINESTONE, BARRY
Address: 1116 DANA DR
COSTA MESA, CA
MECHANICAL PERMIT.,,,..._.,_ -
Phone: 714-901-0500
Zip: 92863
Phone:
Zip: 92626-1633
Status: ISSUED
Applied: 12/07/2005
Contractor: A PLUS HEATING AND AIR CONDITION
Address: 7600 GARDEN GROVE BL
Phone: .714-901-0500
WESTMINSTER, CA Zip: 92863
License: 763154
SCOPE OF PERMIT .
NEW CENTRAL AIR SYSTEM -
MECHANICAL TO INCLUDE: 1 FAU > 100K BTU, 1 GAS PIPING, AND 1x
COMPRESSOR/ABSORPTION SYSTEM UP TO 3 HP/t00K BTII
FEE SUMMARY'
- - TOTAL CALCULATED FEES $62.55
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)�0--..�- .. _
EXPIRATION: This permit shall automatically expire and become void If work is not cornrnericed wlihin 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.
t
FOR INSPECTIONS CALL: (714) 754.5626
ewo-so Mawr
Quantity
Quantity
ISSUE FEE
$23.50
-
Repair I Alt Absorblion Unit
$0.00
0
Inst FAU <100 k BTU
$0.00
0
Repair / Alt Refrigeration Unit
$0.00
0
Inst FAU >100 k BTU
$18.20
1
Venlillation System
$0.00
0
Repair/ Alt Cooling/Heat
$0.00
0
Evaporative Cooler
$0.00
0
Inst / Rep. Recess Wall Htr
$0.00
0
Commercial Incinerator
$0.00
0
Refrig Sys <100 k BTU
$0.00
0
Domestic Incinerator
$0.00
0
Refrig Sys >100 k BTU
$0.00
0
Compressors /Absorption Systems
-
Gas Piping
$6.15
1
Up to 3 hp/ 100k BTU
$0.00
0
Factory Fireplace
$0.00
0
3 To 15 hp/500k BTU
$0.00
0
Hood w/Mech Exhaust
$0.00
0
15 To 30 hp 11,000 k BTU
$0.00
0
VAV Box
$0.00
0
30 To 50 hp / 1,750 k BTU
$0.00
0
Vent Fan / Single Duct
$0.00
0
Over 50 hp / Over 1,750 BTU
$0.00
0
Appliance
$0.00
0
Boilers
Fire Dampers
$0.00
0 -
Up to 3 hp
$14.70
1
Smoke Dampers
$0.00
0
- 3 To 15 hp
$0.00
0
Inst or Relocate Appl Vent
$0.00
0
15 to 30 hp
$0.00
0
Air Handlers < 10000cfm
$0.00
0 -
30 to 50 hp
$0.00
0
Air Handlers>10000cfm
$0.00
0
_
Over_50hp. -
$0.00
0
Floor Furnace
$0.00
0 -
- _.,.OthecMechanical,F.ee..-..-
Floor or Suspend Heater
$0.00
0
_
Investigation Fee
- $0.00
'
Plan Check Fee
S0.00
-
Reinspection Fee
$0.00
- - TOTAL CALCULATED FEES $62.55
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)�0--..�- .. _
EXPIRATION: This permit shall automatically expire and become void If work is not cornrnericed wlihin 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.
t
FOR INSPECTIONS CALL: (714) 754.5626
ewo-so Mawr
C
DECLARAVONS
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 sell-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.
-mrI. a and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which IN permit is issued.
y wow 'Gcoompenlsaallon In_syD)nce carder and policy nu ber are:
LS, Ic-f"-t-� P%P.C�r.� Polity Number.._2QL6 ��Q)C�9__
S,
need not e o leted /f the permit Is Saone hundred dollars ($100) or less.) +
❑ I certify that in :.hope tnco oLnloh'
which this p it Is issued, I shall not employ any person In any manner so as to become subject to the workers'
compensation laws of a,at II 1 ould c me subject to the workers' compensation provisions of Section 700 0l he Labor Code, I shall forthwith
comply with these pr io
--
App11D�1'Sign�a4t�ure: - a6'tg:"�-..
173FDrDOLLARE
LORE TO SECURE WORKERS' CYkAPEN$ATION RADE IS UNLAWFUL AND SHALL SUBIECT AN EM ERTO
IMINAL PENAL ES AN CIVIL FINES UP TO ONE HUNDRED
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE, IME ST, AND ATTORNEYS FEES,
LICENSED CONTRACTORS DECLARATION:
I he bthat 1 em I cense r,provisio s of Ch r 9 (commencing with Section 7000) of Division 3 of the Business and Prof Bions Code, and my license is in full
'en' eHecc�t - Class a ' �-
Cp_Rt gS.SignatJra;— - - ^ „r..,sBa�e1---.. .
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:
1 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 (5500).):
❑ I, as owner of the property. or my employees with wages as their sola compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not appy to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors license Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property lax 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, An 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 WIII 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 Mass Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
......................................... ................................... ..................................................... ............................... ................................ ............................................................... .................................... ................ ............................... .........................................
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code. with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
.............................._.........................______.__._........................................__........_......_.__._......................._................._...........................................................................__............_.................__..........._..........._
3 Does or will the applicanl 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.
............._....... .................... ......._.___......................_................_..............._._.__........................___.........................................._............. ...................................................... _.._................. _............. ._.... I.......... _........... __.....
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 appennit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
......................._......................................_............._............... _.__..._................................_-.....................__............................................................................................................................_................
......_-............._.....
........
_.............
6 WIII any pan of me iia t 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 Ouality 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', affach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certity 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 certity 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 inspe 'on purposes. I agre of to occupy or allow occupancy of any building authorized by this permit until final inspection.
OI Dat
UNIMAx
nd/0�r'Applicant- ^ - f ji- •ate '-,-• -�-
INSPE
ONTYPE
060E 1. INSPEFixed TION System
PE PdIE I[ 200E I Final Mechanical
pAg, �s
1818 Fixed System Final Fire Prevention 206 Final Mechanical �/-(Tf�-+(-'Y)•'T///V�.-F'-� `\V1jv//�p11 W�7_
1288 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
OKAY TO PROCEED -
WITH PLAN CHECK. THIS DO S NOT
CONSTITUTE FINAL PLANNING APPROVAL.
PriorityWOMP
BY' _ DATE 2 OT S I
No
f
QzN-L�>, X�k ��L cF
�tossc-,
r�
0
N N N
d A A
a N �
N r
OOtn
O O O
WOW
xxx
mm
m
Job Address: 1116 DANA DR
Suite No
Vicinity:
Parcel Nunmber: 41207414
Applicant: ALLEN, MARK
Address: 7600 GARDEN GROVE BL
WESTMINSTER, CA
Owner: FINESTONE, BARRY
Address 1116 DANA DR
Status: ISSUED
Applied: 12/07/2005
Issued: 12/07/2005
Phonej - 1-0500 ISSUED BY: .
Zip -863
Phone: "
COSTA MESA, CA - - Zip: r ,92626-1633-"
Contractor:. A PLUS HEATING AND AIR CONDITION
Address:7600 GARDEN GROVE BL -
Phone: 714-901-0500
WESTMINSTER, CA Zip: 92863'- 11,
License: 763154 -
bGUr't Ut YtKlyll l ,
NEW CENTRAL AIR SYSTEM
ELECTRICAL TO INCLUDE: 1 LIGHT FIXTURE, 1 OUTLET AND 1 SWITCH.
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.
r
FOR INSPECTIONS CALL: (714) 7545626
,."a lo'w)
FEE SUMMARY_.;_ ,
'
-
Quantity .
.: a �t., ."
-... Quantity
-
ISSUE FEE
$23.50..
..: Temp Dist System / Lighting
$0.00
0 -
Temp service test'
$0.00
Busway /100 ft
$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 -.
$0.00
'0 --
-- =-` ................up to 10 kva/kw
$0.00
0-
Lighting Fixts -
$1.10
1
.................up to 50 kva/kw
$0.00
0 - - -
Recept Outlets
$1.10
1
.................up to 100 kva/kw -
$0:00
. 0
Switches
$1.10
1
..................over 100 kvalkw
$0.00
0
Non Res Appy
$0.00
0
Low Voltage Equipment
$0.00
0
Res Appl
$0.00
0
-Low Volt Wiling System / Ckl`
$0.00"-'�
0
Service to 200a
$0.00
0
--> Misc. Conduit
$0.00"
0
Service to 1000a
$0.00
0
Misc. Coriductor. -
$0.00
0.
Service over 1000a -
$0.00 "
0
Circus ( gen or ride)
$0.00
0
Motors to 1 hp ".
$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 .
Motors 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 "
,Reins ectionFee' -
$0.00-"
Sign Circuits
$0.00:
0
Temp Pwr Pole
$0.00
-01
- -;TOTAL CALCULATED FEES '$26.80
Intermed Pole
$0.00
0
COMMENTS I 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.
r
FOR INSPECTIONS CALL: (714) 7545626
,."a lo'w)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is Issued.
r
I.Fam and will maintain workers'compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
wdrke 'camper eIII n Insurance carrier and policy number are:
r.: %ectldn need no be completed if fhe permit is valued atone hum dollars ($100) or less.)
❑ certify That In the perform ca of Ih ark for which permi i sued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of III, a greet If hou a ubject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these i
L[App4J%0Slgnature: " ' _,:'Date:
,tee`-•;$7tr,sc
�Y/ARMNGiFAICURE'TOSECURE WORKERSCOMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMP OYER TO CRIMINAL PENALT S ANDIVI RNES UP TO ONE HUNDRED
THOUSAND DOLLARS LS1co,ocoL IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3108 OF THE LABOR CODE, INTER q "T, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aMimnthet Vam Ncensed.under or .sions of Chapter ommencing with Section 7000) of Division 3 of the Busines -and of SIOq Code, and my license is in full
force and`effecL Llc..Y. '_=.ICW��±�-IiI-Cti/r-#' �\ Glassyu
Co Vactor�sLSlgnalure:i 1m\\ I��II-/-1 U ,�p
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby all that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any Violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as Owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Cade: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Drivers 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 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, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title B, California Administrative Code).
❑ As owner -builder, 1 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? ❑Ves ❑ No
(Section 25533 of the California Health and Safety Code, with some exce tions, 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 aqua to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
............................................................................................................................................................................................................................................................................................................................................................................................
3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ NO
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
......
..............................................................................................................................................................................................................-.................-........................................................................... .... ............ ........................................................
4 II 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 ajpplication apemit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? UYeS LJ No
(Section 65850.2 of the California Goverment Code requires that the requested Information be furnished on applications for non-residential building permits).
................................................................................. .__.._._... _..... ......... ..................... _................................. ..... _............. __................... __.......................... -....... _......................... ............................................ ............................... _.................
.
6 Will any pert of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 II a permit from the South Coast Air Quality Management District or other air pollution control district or agency is requiretl 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 F 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 state laws and city or nces relating to building constructlon, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for in p coon purposes. I ogret to occupy or allow occupancy of any building authorized by this permit until final inspection.
tures al Owners ate
L And/OTAuthorized Applicitnt �, (°"S°; te'
CODE f. INSPECTION TYPE PZTE' INTITALi CODE# INSPECTION TYPE QATE INTMEL§
1616 Fixed System Final Fire Prevention 206 Final Mechanical T—/�/�"j7-/jam
1266 Pool Spa Final 208 Final Plumbing l I
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
i
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 1116 DANA DR
Suite:
Vicinity:
Parcel Number: 41207414 Zoning: R1 R1
Applicant: SELL ROOFING COMPANY
Address: 18032 LEMON
Phone: (714) 528-1758
YORBA LINDA, CA Zip: 92686
Owner:
BEMMER,MICHELLE
Permit:
$167.25
Address
1116 DANA DR
SMTP Com:
$0.00
Other:
$0.00
Phone:
714-546-0416
COSTA MESA, CA
Zip:
92626-1633
Contractor:
SELL ROOFING COMPANY
Address:
18032 LEMON
Phone:
(714)528-1758
YORBA LINDA, CA
Zip:
92686
License:
323842
Arch :
Address:
Eng:
Address:
ISSUED BY:
Status: ISSUED
Applied: 04/15/2003
Issued: 04/15/2003
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
TEAR OFF WOOD SHAKE, INSTALL 1/2" OSB UNDER LITE CONIC. EAGLE TILE 5.7 PSF. ICBO 4660.
Plan Check:
$0.00
Permit:
$167.25
SMIP Res:
$0.89
SMTP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total: $168.14
SETBACKS
MAIN STRUCTURE Front 0-0
ACCESSORY Front 0-0
PARKING Existing: 0
NOTES:
FEE SUMMARY
PLANNING & ZONING
Rear 0-0 Left 0-0
Rear 0-0 Leh 0-0
Required: 0 Proposed: 0
Calc Valuation:
Claim Valuation
Right 0-0
Right 0-0
$8,900.00
$8,900.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued. ,
❑ I have endwill maintai workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' n In/� ce ca '' antl policy number are:
Carder:. Policy Number: / V e"
(This section need not be completed if the permit is valued of one hundred dollars ($ f00) 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, end r that If I s Itl bac me subject to the workers' compensation provisions of Section 3700 of he Labor Code, I shall forthwith
comply with these provisions. t p
Applicant Signature: '� ,/�il Date:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DCLLARE (S100.00)1, 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 Pr13r 'sion f aptommencing with Section 7000) of Division 3 of the Business and Prgt�SS 1;58, and my license is in full
force and effect. Lic. 8 moi' Class N
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirn 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 througn his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct theProject (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers 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 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 Costs Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
.....................__.............................................. ,.........._._........_...................................__......................_............_.................._.__.................. __..........................................................._...............................
_...............
_.............
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
............................................................................................................................................................................................................................................................................................................................................................................................
3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
..................................................................................................................................................................................................................................................................................................................................................................................
4 It 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? 8 Yes a No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
fi... _Will any part of the leciiity to be constructed under permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No _
(If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
..........................................................................................................................................................................................................................................................................................................................................................................................
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ yes ❑ No
.......................................... ................................................................................._........................ ........................... __........................... _._...................... .......................... ......................................... _.......................................................................
8 (If yes'. attach certificate of Compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signa Oct' egal Ow r(s 1 / % D
An r Authorized Applicant `T-IF Otte
CODE r, INSPECTION TYPE RiTRIALS SgPF.! INSPECTION TYPE gaj[ INTIMALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY OF COSTA Mks %NSTRUCTI N PERMIT
Project Address i ►�042
Applicant's MailirJ�g��Addjdlr�ess �s
IPAUD 0A
Owner's Name j L"v Phon V -
Address
Arch/Eng. License No.
Address
Contractor's Name ' n -Phone
Address (mailing)
City Licence No
LICENSED CONTRACTOR DECLARATION'
1 hereby affirm that 1 am licensed under provisions of Charter 9 (commencing
with section 7000) of Division 3 of the Business and Professions Code, and
my license is in f"�etD,
License las�KE COARATIONaby ffirmtte of consent to self -insure or a certificate
Workers' Compensation Insurance, or a certified ycopy thereof (Section
,00; Lab.1 .
Policy No: Company-,
ertified cop Is hereby furnished.
Ce i fled with the city�iLl'tl{, ig Lio S
Date e Applicant,
EXEMP ON ROM WORKERS' COMPENSATION DECLARATION
(Thissection need not be completed if the permit is for one hundred ($100) or
ess).
certify that in the performance of the work for which this permit is issued, I
snarl not employ any person in any manner so as to become subject to the
Workers' Compensation Laws ofCalifornia.
Signature
NOTICE: -If, after making this declaration, you sh Cod become subject to the
Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I affirm that there is a construction lending agency for the performance
off the the work for which this permit is issued (Section 3097_ -Civ. C.)
Lender's Name
Lender's Address
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Section. 7031.5 Business and Professional Cade: Any City or
county which requires a permit to construct, alter, improve, demolish or repair
any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he/she is licensed pursuant to the provisions of
the Contractor's License Law (Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and ProfessionsCode)or that he/she is exempt
herefrom and the basis for the alleged exemption. Any violation of Section
;031.5 by any applicant for a permit subjects the applicant to a civil
LJpenalty of not more than five hundred dollars ($500).
1, as owner of the property or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered
for sale (Section -7044, Business and Professional Code: The Contractor's
License Law ones not apply to an owner of a property who builds or improves
I thereon,. and who doessuchwork himself/herself or through his or her own
employees, provided that such improvements are not intended or offered for
sale. If, however, the building.or improvement is sold within one year of com-
pletion, the owner will have the burden of proving he/she did not build or Im-
-M rovr the purpose of sale).
1e fo, as'owner of the property, am'. exclusively contracting with licensed con-
tractors to construct the project (Section 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner.of property who
builds or improves thereon, and -who contracts for such projects with a con-
tractors) license pursuant to the Contractor's License Law). I am aware that
proof of their Worker's Compensation insurance should be provided to me.
❑ 1 am exempt under Section B. & P. C. for this reason
Date Owner
I hereby certify that I have rea
information is correct. I agree to
and state laws relating to buildil
sentatives of this city to enter
inspection R+dY+gslry4i/ n n "
Signature[_(fd
cen
Drivers' Lise or SS 1r
PERM as 39 TRACT NO. LOT NO. UNIT NO.
TYPE OF CONSTRUCTION 0 NEW LJ ADD ALTERATION REPAIR:
❑ CONVERSION ❑ DEMOLISH ❑ OTHER _ A P #
DESCRIPTION OF WORK/USE OF BLDG.
TYPE OF PERMIT LJ GRADING LJ FyNNOATION LJ STRUCTURAL
❑ TENANT ❑ ELECTRICAL LlIrLUMBING ❑ MECHANICAL
❑ OTHER
PROJECT DESCRIPTION SO. FT. OCCUPANCv_
.CONSTRUCTION TYPE VALUATION $
ZONE GRADING CU.VDS. ACRES
Remarks: - . —
FEES
Bar Sink
Showers
Backflow Preventer
Service Sink
Backflow Irrigation
'Sewer Cap
Bathtubs
Sewer Connection
Clarifiers
Solar Collectors
Dishwasher
Solar Piping _
Drinking Fountains
Solar Tank
Floor Drains
Swimming Pool w/Spa
Floor Sinks
Urinal
Gas Service Outlets
Water Closet
Interceptors
Water Heater
Kitchen Sink
Water Service --
Lavatories
Auto -Wash - -
P -Trap r
Laundry Trays
Roof Drains
TOTAL FEE
Reinspection Fee $15 I I Issue Fee I $ 3
0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor
S Main Buddir
E
T Front
B Rear
A
C Right
K
S Left ;
Ping. Ref. #
Planninq Notes:'
3448 9%19/86
Zone
Accessory Builiiing:
Parking Req./Provided
ELECTRICAL
Boiler
.Transformer ❑ 15.50 KW
❑ 50+KW 1
Hood or Type I ❑
Canopy Type I I ❑
Meter ❑up to 100 amps
Dishwasher
Meter Dover 100 amps
Duct - Under Ground
Sub Panel'
Duct -Structural
. Motors ❑0-1 HP 01X-8
Refrigeration System'
❑0-100,000 BTU ❑ 100,000 BTU
Inc.Solar ❑9-15 HP 016-15+
Fixtures
Microwave
Duct - Ventilating
Pole Light
Outlets
Exhaust System ❑ Multiple El
Switches
System Repair/Alteration
Garbage Disposal
Standing Sections
Generator 110-5 KW 05-15 KW
Firepl/Fact Bit. IC80#
MICROFILM
Fire Dampers
MECHANICAL
$
TOTAL FEE
Heating System & Ducting
❑0-100,000 BTU 0100,000BT
Registers -
Reinspection Fee
$15
- Issue Fee
$ 3
0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor
S Main Buddir
E
T Front
B Rear
A
C Right
K
S Left ;
Ping. Ref. #
Planninq Notes:'
3448 9%19/86
Zone
Accessory Builiiing:
Parking Req./Provided
ELECTRICAL
Automatic Washer
Construction Pole Sub..
.Transformer ❑ 15.50 KW
❑ 50+KW 1
Cooking Unit
Meter ❑up to 100 amps
Dishwasher
Meter Dover 100 amps
Dryers ❑Gas ❑Electric
Sub Panel'
Fan _
. Motors ❑0-1 HP 01X-8
F.A.U.
Inc.Solar ❑9-15 HP 016-15+
Fixtures
Microwave
Device Boxes
Pole Light
Outlets
Range
Switches
Sign
Garbage Disposal
Standing Sections
Generator 110-5 KW 05-15 KW
Trash Compactor
Reinspection Fee 1 $15 1 1 Issue Fee
DEVELOPMENT SERVICES REQUIREMENTS:
Zoning Approved By
Building Approved By
Application Issued By
5.00 .TL
FEES
$ 3
Z
O
N
I
N
G
R
E
Q
M
T
S
PLAN CHECK -25%- $
-SUMMARYOFFEES
BUILDING PERMIT , $
SMIP
$
PLAN CHECK -
$
- PERMIT
-
PLUMBING
$
-ISSUANCE
$
PLAN CHECK 250/.
$ .
ENERGY P.C.
$
ELECTRICAL
$
- GRADING
$
PLAN CHECK 50%
$
MICROFILM
$
MECHANICAL
$
TOTAL FEE
$ (,:�-Q 0
PLAN CHECK -25%- $
CONSTRUCTION AND PLANNING
APPROVALS Permit #
Date
Inspector
POOL & SPA
APPROVALS Permit #
Date
Inspector
v
1. Temporary Electrical Service or Pole
52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd.
53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd.
54. Forms '
4. Electrical Conduit-Undrgrnd.
55. Electrical Bonding �.
5. Steel Reinforcement
56. Rough Plumbing & Pressure ,Test
T
6. Electrical UFER Grnd.
57. APPROVAL TO COVE R -G
7. Footings
58. Electrical Conduit-Undrgrndj
8. Foundation
59. Gas Pipe, ❑ Undrgrnd., Test:
9. Water Pipe-Undrgrnc .
60. Backwash Lines, P -Trap, ❑(Uhdrgrnd.
10. Structural Floor System
61. APPROVAL TO DECK ":t}
11. Property Sewer Line & House Connection
62. Backwash & Receptor -Final
12. Sewer Cap
63. Heater & Vent -Final
13. Roof Drains
64. Plumbing System - Final
14. Rough Plumbing
65. Electrical -Final
15. Rough Electrical -Conduit
66. Solar System -Final
16. Rough Electric Wiring
67. Fencing & Access Approval
17. Rough Wiring Sign
68. APPROVED FOR PLASTERING
18. Rough Electrical -T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning
FIRE DEPT. REQUIREMENT
APPROVALS Permit # -
20. Rough Factory Fireplace
21. Ducts, in Structure
70. Underground Hydro
22. Ducts, Ventilating
71. Product Piping ❑ Gas ❑ Oil
23. Gas Pipe -Rough & Test
72. Underground Flush
24. Roof Framing
73. Undergrnd. Storage Tank ❑ Gas ❑ Oil
25. Roof Sheathing
74. Overhead Hydro
,
26. T -Bar Ceiling (Structural) & Monocoat
75. Dry Chemical
27. Frame and Flashing
76.Dry Standpipe
28. Lathing & Siding
77. FIXED SYSTEM FINAL
29. Insulation
78. FIRE PREV. FINAL
30. Drywall Nailing
HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat
79. FINAL INSPECTION
32. Electrical Power Meter -Final
80. FOOD CERTIFICATE ISSUED
33. Final Electric
Notes:
34. Final Heating & Air Conditioning
35. Final Gas Pipe -Test
-
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
/4�47
L4FO
39. Water Service -Final
40. Gas Service -Final
41. Solar Domestic -Final
'
42. Backflow Preventer
43. Backflow Irrigation
'
44. Landscape Irrigation System
- -
45. Sound Attenuation
-
46. Handicap Regulations
- ..
47' FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
C_
-45 -3
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill in Completely — Use Ink Only
OWNER Properties West
MAIL
clry Newport Beach- CA
NO.
p 67.5-49101
BRANCH
ADDRESS
ARCHITECT h___,_r.__s__ TEL.cnn nnro
ADDRESS 224U NaNZWrt IJIV(l_ , NP j2(L
CONTRACTOR Owner
ADDRESS
TEL
CITY NO.
STATE CITY
LIC. NO. LIC. NO.
SIZE
ILOT A NO. OF SLOGS,
OF -Approx. 60 X 80' NOW ON LOT
USE OF
EXISTING BI -OG.
Separate permits are required for
electric, plumbing and heating work.
USE OF BUILDING AND WORK TO BE PERFORMED
#4
';OV 10-77PCcnsMIBn00 569* ***122.64
APPLICATION FOR STRUCTURAL PERMIT
ECEIVED BY I DATE RECEIVEDY nATF ISSUED
BUILDING
TRACT NXhh I LOT 1M I BLOCK
VALUE
OF w I USE OF
-L1 PLANS /.--I BUILDING kilm J/ j
V ARDS APPROVED YARDS APPROVED YARDS APPROVEDEDDsD
MAIN BUILDING ACCESSORY BUILDING
BET. ^ET. MAIN
I hereby acknowledge that I have readijl Mares
state
rmation �n
that the above InfoIs <one<t o agree to comply with REQ
t- [p�T �
all laws regulating building construction, and I shall not employ I L REQ f�: r:f L191 >
any person in violation of the workman's compensation laws of EN 1 0
the State of California.
I hereby certify that I em properly licensed as a contractor under
SO. FT. 2790 m
the Sure of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9, and that such licenses are in full force and affect, or 1 THE PURPCIS OF ESTABLISHING A PERMIT FEE ONLY;
em exempt from the provisions of the State of California Business VALUATION PERMIT FEE 3 Y
pnd Professions Code, DIW6on 3, Chapter 9. m
PLAN CHECK $ 117..50 0
Signature of /// �G��—!/�iiw'/L/i^f /La/-��1/
Permitter, �>�'� s 73, 400. TAX s $,14
Authorized Agent G as1Gl+ti� TOTALPAID E y
dJ'ar
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
"EC -9-77�C �SNO 515 J*** 235.00
APPLICATION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely — Use Ink Only
RECEIVED BY I GATE RECEIVED
DATE ISSUED
BUILDING
ADDRESS
PERMIT NO.
OWNER
A.P. NO.
BUILDING
MAIL
ADDRESS
ADDRESS
TEL.
CITY NO.
TRACT
LOT BLOCK
CONSTRUCTION
W
A
ALTER
REPAIR
LENDER
BRANCH
OWNER
ADDRESS
UE
S $
ARCHITECT TEL.
OR ENGINEER
FIRE
ADDRESS
ZONE TYPE GROUP
APPROVED
CONTRACTOR o—
BY DATE
ADDRESS
TEL.
ZONE
NO. OF
USE OF NEW
CITY NO.
PLANS
BUILDING
STATE CITY
YARDS APPROVED
YARDS APPROVED
LIC. NO. LIC. NO.
MAIN BUILDING
ACCESSORY BUILDING
SIZE
NO. OF BLDGS.
IFROM C/L STREET)
OF LOT
NOW ON LOT
FRONT FT.
FT.
USE OF
EXISTING BLDG.
R. SIDE FT,
FT.
Separate permits are required for
L. SIDE FT.
FT.
electric, plumbing and heating work.
REAR FT.
FT.
USE OF BUILDING AND WORK TO BE PERFORMED
DISTANCE BET.
BET. MAIN &
MAIN BLDGS.
ACCESS. SLOGS.
'
VAR. 46
DATE
s
C.U.P.sp
APPROVED
y
APPROVED
BY
1 hereby acknowledge that I have read this application and state
that the above Information Is correct and agree to comply with
all laws regulating building construction, and 1 shall not employ
any person in violation of the workman's compensation laws of
the State of California.
I hereby certify that I am properly licensed as a contractor under
SQ. FT. i
THE AMOUNT SHOWN UNDER VALUATION IS FOR i
the State of California Business and Professions Code, Division 3,
Chapter 9, and that such licenses are in full force and affect, or 1
THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exempt from the provislons of the State of California Business
and Professions Code, Dn 3, Chapter 9,
ivis b
VALUATION
PERMIT FEE i
i
PLAN CHECK $
Signature of
/J
TAX E �
/
Permittee$
'iQ/
Authorized Agent JC:.l cG
g
TOTAL PAID
--chi:
E