HomeMy WebLinkAbout627 DANUBE DR - Building PermitsCITY OF COSTA MESA •
O MFs,p BYILDING DIVISION
F� � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • w.wv.ci.costa-mesa.ca.us
� FOR INSPECTIONS CALL: (714) 754•5626
�°'°"°"°fi PERMIT NUMBER: E09-00304
PERMIT TYPE ELEC
APN: 934050$8
JOB ADDRESS: 627 DANUBE DR CM
Vicinity:
STATUS: ISSUED
DATE ISSUED: 1 211 612 0 0 9
ISSUED BY: KJB
Suite/Unit:
SCOPE OF WORK: REPLACE FAU AND A/C UNIT. A/C UNIT IS INSIDE THE DWELLING. NO HOA LETTER REQUIRED.
OWNER: ZAMgON, NICHOLAS
PHONE: 774-q04-6354
APPLICANT: JACOBY, ERIC
PHONE:
CONTRACTOR: SERVICE CHAMPIONS
Address: 22911 SAVI RANCH PKWYUnit
City/5tate: YORBA LINDA, CA ZipCode: 92887
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $35.80
Reinspection Fes $0.00
TOTAL FEES $35.80
Address: 627 DANUBE WAY Unit:
City/State/Zip: COSTA MESA, CA
Address: Unit:
City/State/zZip:
License No. 799170
PHONE: 714•777-7777
CELL:
0
.:i�4_(�i�=�Q�
,. - . �^D�
NOTICE: The work authonzed by this permit shall comply with all applicable handicap access requirements under California statutes antl related
regulations. (Ord. No, 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permil 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 vrill result in the expiration of this permit.
LODE1. INSPEC110NTVPE OATE INTITIALS CO�E9 INSPECPONTYPE �ATE IN11iIAL5
7616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing � /� /
200 Final Re-Root 210 Final Eleclfiwl ���� K�' '`""�
201 Final BIocWRetaining Wall 212 Final Fire Prevention
202 Final Factory Fi�e Place 220 Final Planning Approval
203 Final Sign - 222 Final Site '
204 Final Demolition 250 Final Building/Occupancy
WORKERS' COMPENSATION DECLARATION:
I hereby aHirm untler penalty of perjury one of the tollowing declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'
cOmpensalion, a5 provided lor by Setlion 3700 of Ihe Labor Cotle, for lhe
e rmance of Ihe work for which Ihis pertnit is issued.
■. I have and will maiNain workers' compensation insu2nce. as required by
�s n 3700 of the Labor Code, for the peAortnance of the v.ork fw which this
permit is issued. My workers' wmpensation Insurance wrrier and policy
number are: �
�-� �i¢ J � S �`/ �
(Tnis seqm neeE no1 �e cumdeted a Ne peiml & valueC at me nunared �'lars (St00J a less )
r�r, �„��,: e 200 8 o v 9� so z-
❑ I certify that in the peAormance of [he vrork for which this permit is
issued. I shall not employ any person in any manner so as to become subject
b the workers' compensation laws o! Cali(omia, and agree that if I should
become subject to the workers' compensation provisions of Section 3700 of
the Labor Co , I shall fort 'th comply with these provisio s.
� O.
_ __•+•• tilre`�
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 DOLLARS
($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000) o( Division 3 ot the Business antl Professions Code. and
my license is in full force antl eflect.
Lic. '� � � ��� �- �Z(�
� - � �i//,� /0 9
yCom�7 �-, � nalure T�'ale�
T
CONSTRUCTION LE ING AGENCY:
❑ I here6y aKrm that lhere is a construction lending agency for the
pedortnance of the v.ork (a which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lentler's Address:
Date
OWNER•BUILDER DECLARATIONS:
I hereby affirm that untler Oenalty of perjury that I am EXEMPT FROM 7HE
CONTRAC70RS LICENSE LAW for the follovnng reason (Sec. 7031.5,
Business and Pmfessions Cotle: Any city or county which requires a permit to
conslruct, alter, improve, demolish, or repair any structure, pdor to its
issuance, also requires the applicant for such permit to fle a signed statemenl
lhat he or 5he is licensed pursuanl lo Ihe provisions of the Coniractors
License Law (Chapter 9(commencing with Section 7000) of Division 3 of the
Business antl Protessions 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 suhjects the aDPlicant to a civil penalty of not more Ihan
five hundred dollars ($500).):
❑ I, as ovmer of lhe property, or my employees with vlages as their sole
compensalion, WILL DO THE WORK, and Ihe swcWre is not intended or
oftered for sale (Sec. 7044, Business and Protessions Code: The Contractors
License Law dces not apply to an owner of property who builds or improves
thereon, and who does such vrork himself or herself or through his or her ovm
employees, provided that such improvements are not intended or ofteretl for
sale. If, however, the building or improvement is sold within one year of
completion, t�e ovmer-huilder will have Ihe burtlen 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 CON7RACTORS to cons(ruct the prqect (Sec. 7044. Business and
Professbns Code: The cont2ctors License law tloes not apply to an owner of
property who builtls or improves thereon, and who contracts (or such project with
a contractor(s) license pursuant tothe Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for lhis reason:
SignaWre
305]46 (]/0])
Owner ID venfied by dnvei � license. ❑ Yes ❑ No
Driver's License No. Expires:
Veri(calion of Ownership by (Iype of document, i.e. - property tax bill or deetl):
DIVISION OF IN�USTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certAy that no excava[ion frve (5) or more feet in depth into v.hich a
person is required to descend, vrill be made in connectbn vrith xqrk authorized
by this permil, and that no building sWcture, scaffdding, falsework, or demolition
or dismantling thereof, will be more �han thirty-sa (36) feet high. (Chap. 32, Grp
2, M 2, Sec. 341, Title 8, Califomia Administrative Code).
❑ As owner-builder, I will not employ anyone to tlo vrork which would
require a permit from the Division of Industrial Safety, as no[ed above, unless
such person has a permit to do such v,nrk trom the division.
pppliG3nt's 9gn31ure Dale
Division of Industnal Safety Permit Number
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or fuNre building occupant need to file and
certify a 8usiness Plan (or emergency response lo release or lhreatened
release of a hazartlous matenal? ❑ Yes ❑ No
(Section 25505 ot the California Health and Safety Code requires, wiN some
exceptions, Ihat a Business Plan be filed with the Costa Mesa Fire
Departmem by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or grealer than a weighl o(
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at stantlartl temperature antl pressure�.
2. Does or will Ihe applicant or present or fuWre builtling occupant neetl to file
a regisVation fortn for acutely hazartlous materials? ❑ Yes ❑ No
(Section 25533 of the Califomia Health and Safery Code, with some
ezceptions, requires registration with the Costa Mesa Fire Department by
each business which al any one [ime has on hand a quan[ity of acutely
hazardous ma[erials equal to or greater than a weight of 500 pounds, or a
volume ot 55 gallons, or 200 cubic feet of compressed gas at stantlartl
temperature antl pressure).
3. Does or will Ihe applicanl or presen[ or future building occupanl need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 0( the California Health and Safery Code pmvides thal the
Costa Mesa Fire Department may require the preparation, certification and
filing wilh the Fire Department ot an RMPP by businesses which are required
to register acutely hazardous materials with [he Fire Departmenl.
4. I( an RMPP is presently required, has Sec[ion 25534 of the California
Health antl Safety Cotle been fulty complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or fuNre building occupant require for
lhe wo�k which is Ihe subject of this application a pertnil for such construction
or modification from the South Coast Air �uality Management District or (rom
any other air pollution coMml tlisMct or agency? ❑ Yes ❑ No
(Section 658502 of the Califomia Govemment Code requires Ihat the requesled
infortna�ion be fumishetl on applications for non-resitlential building permits).
6. Will any part of Ihe facility to be constructed under this pertnit be wilhin
1000 feet (rom the outer boundanes ot a school? ❑ Yes ❑ No
Qt'yes", the tacility must meet the requirement o( Seclions 25534 and 42303
of the Califomia Health antl Safety Cotle).
7. I( a permit (mm the South Coast Air Qualiry Management District or other
air pollWion contml disMct or agency is required (or the work which is Ihe
subject of this application, have all of the disclosures prescnbed by California
Health and Safety Code Section 42303 been made? ❑ Ves ❑ No
B. (If'yes", attach certificate of compliance from the appropnate air pollution
contml oKcer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
information given above is correct I agree to comply with all stare laws and
city ordinances regarding Hazardous Materials antl Emissions.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalry of perjury that I have read this application and state that
the information given is correct. I agree to comply with all slate laws antl city
ordinances relating to building construction, antl authorize representatives of
the Ciry of Costa Mesa to enter upon the above-descnbed pmperty for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permi[ until (nal inspection.
ignaWreolleg er(s) /ale
� ! �
�MIa�Authori Appliqnt �.+�>Dale��
•' � _`�^.� -
�
CITY OF COSTA MESA
�o °"'F B111LDING DIV/SION
i�� 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (774) 754-4856 • www.ci.costa-mesa.ca.us
:
� FOR INSPECTIONS CALL: (714) 754-5626
�'"'°""°� PERMIT NUMBER: P10-00084
PERMIT TYPE PLUM
APN: 93405088
JOB ADDRESS: 627 DANUBE DR CM
Vicinity:
STATUS:
DATE ISSUED:
ISSUED BY
Suite/Unit:
ISSUED
0612212010
RMD
SCOPE OF WORK: PLUMBING PERMIT FOR WATER HEATER CHANGE OUT FOR A SFD. COMPLIANCE FORMS ATTACHED
TO JOB CARD AND CITY PERMIT.
OWNER:
PHONE:
APPLICANT:
PHONE:
Address:
City/State:
ARCHITECT:
ENGINEER:
THAYER,KONDACE
DRAGON, VENTI
B66-692-5273
Address: 627 DANUBE WAY
City/State/Zip: COSTA MESA, CA
Add2ss: 1235 GRAND AVENUE
Ciry/State/zZip: SPRING VALLEY, CA
CALIFORNIA DELTA MECHANICAL INC License No. 811114
1235 GRAND AVENUE PHONE: 800-898-0008
SPRING VALLEY, CA ZipCode: 91977 CELL: 866-692-5273
License No. PHONE:
License No. PHONE:
PLUMBING PERMIT FEE SUMMARY
PLAN CHECK FEE:
PERMIT FEE:
TOTAL FEES:
$0.00
$35.80
$35.80
NOTICE: The vrork authonzed by this permit shall comply vrith all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-27-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order (or the work authonzed under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obWined. Failure to obtain inspections and final approval will result in the expiration of lhis permit.
CO�D „E� INSPECTIONIYPE DATE INTITULS CODE� INSPECTIONTYPE DRTE INTI71pL
1618 Fixed System Final Fire Prevention 206 Final Mechanical �j.�'
7268 Pool Spa Final 208 Final Plumbing 7- 1,�i�j� �%m CA/�
Z00 Final Re-Root 210 Final Eletlncal
201 Final BIOCWRe�aining 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
WORKERS' COMPENSATION DECLARATION:
I hereby aKrm untler penalty ot perjury one o( the follovnng tleclarations:
❑ I have and will maintain a certi(cate of consent to self-Insure for vrorkers'
compensation, as provitled (or by section 3700 of [he Lahor Cotle, for the
p�e/Aormance of the work for which this permit is issued.
pp I have and will maintain v.vrkers' compensation insurance, as required by
sectbn 3700 of the Labor Cotle, for the performance of the vrork for which this
permit is issued. My workers' compensation Insurance carrier and policy
number are: j'�
Carrio�i:� �%�TE � (//�o
(ilrk sertm needipf be /m�mde�te/tl �oithe qpermrt s valued al one huntl2E Cdlars (5f 00) a less )
P� oF!Iicy Number: /o �/Op• �
❑ I certify Ihal in ihe pedormance of [he v✓ork for which this pertnit is
issued, I shall not employ any person in any manner so as to become subject
to the workers' compensation laws o( California, and agree Ihat if I should
become subject to the workers' compensation provisions of Section 3700 of
[he Labor Code,, �I hall (orthwith comply with Ihese pmvisions.
!��/+iT. � �ie9�o�✓ fJ6�d��
AppllranfsSignatdre- CDeieY
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE L480R CODE. IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrm that I am licensed under provisions o( Chapter 9(commencing
wilh Section 7000) of Division 3 of the Business and Professions Code, and
my license pis in full force antl effect.
Lic_C-.«,O ����7 l-Ciass # C �-��
L' //
_./�Ei!/T.i._.7%f�6'pN o6 a ��
V " Gonuactor's Signawre [� ate
CONSTRUCTION LENDING AGENCY:
❑ I hereby affum that ihere is a consimctbn lending agency for Ihe
pedortnance ot the v.ork for which this pertnit is issued. (Sec. 3097. Civil Cotle).
Lender's Name:
Lender'S Address:
SgnaWre
OWNER-BUILDER DECLARATIONS:
I hereby affrm that under penalty of perjury that 1 am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5,
Business and Professions Code: Any ciry or wunry which requires a pertnit to
wnstruct, alter, improve, demolish, or repair any strucwre, prior to its
issuance, also requires the applicant for such permit to fle a signed statement
that he or she is licensed pursuant to the provisions of the Contracrors
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 tor a permit subjects the applicaN [o a civil penalty of no[ more �han
five hundred dollars (5500).):
❑ I, as owner o( the property, or my employees with wages as their sole
compensation, WILL DO THE WORK, and the structure is not intendetl or
offeretl for sale (Sec. 7044, Business and Professions Code: The Conlractors
License Law does not apply to an ovmer of property who builds or improves
thereon, and who does such vrork himself or herself or through his or her ovm
employees, provided ihat such improvements are not intended or oRered for
sale. If, however, the building or improvement is sold vnthin one year of
completion, the owner-builder will have the burden of pmving that he or she
did not builtl or improve for purpose of sale.).
❑ I, as ovmer of the property, am EXCLUSIVELY CON7RACTING WITH
UCENSED CONTRACTORS to cons[rucl [he project (Sec. 7044, Business and
Professions Code: The contractors License Law dces not apply to an ovmer of
property who builds or improves thereon, and who contracts for such pmject with
a contractor(s) license pursuant to the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
Sgnalure Date
3051-46�9I0])
Owner ID verified by drivers iicense. ❑ Yes ❑ No
Dnver's License No. Expires:
Veri(cation of Ownership by (type of tlocument, i.e. - property tax 6ill or deetl):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby cedHy ihat no excavation frve (5) or more feet in tlepth into vfiich a
person is required ro descend, will be made in conneclion with work authorizetl
by this pertnit, and that no building structure, scaffdding, falsework, a demolilion
or dismantling thereol, vnll be more than thirty-su (36) feet �igh. (Chap. 32, Gry
2, M 2, Sec. 341, TUe 8, Califomia Administ2tive Code).
❑ As ovmer-builder, I will not employ anyone lo do vrork which woultl
require a permit fmm the Division of Industrial Safety. as noted above, unless
such person has a permit to do such wnrk from the tlivision.
Applicanfs SignaWre Oale
Division of Industnal Sa(ety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the appliwnt or present or future builtling occupant need to (le antl
certify a Business Plan for emergency response to release or threatened
release of a hazardous matenal? ❑ Yes ❑ No
(Section 25505 of Ihe Califomia Health and Safety Cotle requires, with some
exceptions, that a Business Plan be fletl vrith lhe Costa Mesa Fire
Department by every business which has at any one time dunng a reporled
year a quantiry o( hazardous marenals equal lo or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet ot compressed gas
at stantlartl temperawre and pressure).
2. Does or vnll the applicant or Dresent or future building occupanl need to fle
a registration fortn for aculely hazartlous materials7 ❑ Ves ❑ No
(Seclion 25533 of lhe Califomia Health and Safety Code, wilh 5ome
exceptions, requires registration with the Costa Mesa Fire DepanmeM by
each business which at any one time has on �and 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 compressetl gas at sWndard
IemperaNre and pressure).
3. Does or will Ihe appliwnt or present or fuNre building cecupanl neetl to
prepare an RMPP (Risk Managemen[ and Prevention Program for acutely
hazardous materials�? ❑ Yes ❑ No
(Section 25534 of the Califomia Health antl Safety Code provides that the
Cos[a Mesa Fire Depanment may require the preparation, certification and
fling with the Fire Department of an RMPP by businesses which are required
ro register acutely hazardous materials with the Fire Department.
4. If an RMPP is presenlly required, has Section 25534 of lhe California
Health and Safety Code been fully complied vrith? ❑ Yes ❑ No
5. Does or will the applicant or preseM or future building occupant require /or
the vrork which is Ihe subject ot this application a permit for such conswction
or modi(wtion (rom the South Coast Air Oualiry Management District or trom
any other air polWtion control districl or agency? ❑ Ves ❑ No
(Section 65850.2 of the Califomia Govemment Code requires ihal lhe requested
information be fumished on applications fa rron-residential building permits�.
6. Will any part of the facility to be constructetl under Ihis permit be vrilhin
1000 feet from the outer bountlaries of a school? ❑ Yes ❑ No
(I( "yes", the faciliry must meet Ihe requirement of Sections 25534 and 42303
of lhe Califomia Health and Safery Code).
7. If a pertnit from the South Coast Air Duality Management DisMct or olher
air polWtion contml district or aqency is required for the work which is the
subject of this application, have all of the disclosures prescribed by California
Health and Safery Code Section 42303 been made? ❑ Yes ❑ No
8. Q� yes", attach certificate of compliance from the appropriate air pollution
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify that under penalry o( perjury the
infortnation given above is correcL I agree to comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
SignaWre Da�e
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
ceAify under penalty of perjury that I have read this application and state that
the information given is correct. I agree to compty with all state laws and city
ordinances relating to building conswction, 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
authorizetl by this permit un[il fnal inspection.
SiB��ayt �e ol Legal Owneqs) Date
�/�NTi ,�iP�'Gvd d6�o�o��/�
FAM/a�u�Ihonz20yAP�liwnl Cpafe�'�Y--ti
ga,s or proponc fired, mld
V✓ater Hr:rtu''Iype/I�ucl
erceed 50 p,aflanr. Not wamr pipe insula(ion from
ionent pnckpKCt in a(1 climale:onGs.
UistributianTy�e ( Num6erin � Tauk
/ndividual dwellingUHW hen(ers rmul be
to the.tftchen(sJ and on al! undergrov�td hol
T'i%IEfDiII �I�9IIK
CaagyPactoror Ws��lnfion
9ficrmnll?H�r.iencv R-Vnlue�
l. Indicate Type (Storage Gas, Hen( Pvmp, Irtrtanraneov; erc) . �
2. Reci�culaHng systemt aerving mulfq�lr. riwellingwftr aDwli meet therecirculatlon reguiremenis of§150(n). The Prercripiiv¢ reyuirementa do
nor a(!ma the insmllallon af a merrcu(ating waler hentlng.rysren� fo� sing(e dwelling wiu. �
3. The ezfema/ woter heoting tank and pipea s6all be intvlared ro meet the requiremenv of¢ISOQJ.
• I ccrtifv tLat this CerliLcrtc
� � (^ ( �)
ble O CEA or O CEPE
Phone:
Rlob— lo�l ti- 52� 3
iesponvble Bw7ding Designer's DeclaratiunStatement
• I� eligible imder Division 3 otthe Celifutnia Busiuus �d Yrofessions Code [o acceptresponsibiliry for We building desip� idmtiGed on 7fus
CetliSca[e of Camplisnce.
e I cectify that thn wecgy Ceahues aod perCoicnaoce specifications for the bwldmg desiy� SdmuSed on this Certificate of Complian� wnLocm to
�he reqniicmmts of Titic 24, Pmfs I m�d 6 of Ihe Celil'omia Code bf Regulations.
e ILe buildiug design Icntwes ideu�ed ou Ihiy Cerrifiea[e af Campliaoce ere consis[rn[ with t6e infocmalion provided m document this
building dssipp oo the otha� appGcah(e camplieace foems, woc4sheets, calc�ilation„ plens and �eeifications suhmilled in ll�e en(orcemwt
DaYI: j
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License: '�' I
Phonc'
1%or assla�tance or qrrestioua� regm�ding the Li�c�gy SYaxdards, ron7act lhe Lnergy Ilotline at: 1-o DU-77d-3300.
Regrstralion Numher: __ 2egis�ra�ion Date(I'iine: HERSProvidec
2008 Hesiden(ia! C'omnlim�ce Fm�m.e 1•ebruary 2010
INSTnLLAT10N CER'PII�ICA'I'E CF-6R-�'IECH-01
Domestic Hot N'nter (DHN') (Pa e 1 of T
$ile Address: F(:�nfm�cement AFencp: Ycrmit \umber.
(n�-i �/fY1ti� �i�i� I t�i�� ��t�ik
1. WATFk 31F,ATING SVS'PEMS:
Uis�riFmiw� ftaccd
CEC l'YPc If flo! Inpw(kW 7ank Smndby
Hu�cr CcriiScJ Mfr Namc C Modcl (StC, Point-oG Rcci¢nla�ion, Identiu�l �� Vulnmc 1>(6cicnty I.us.
T c N�nnhcr Usc,ctc) ConlrolTV c S s�cim NIWIv)� vllons (liP,RG)I ���I
L� E j Vy�
�'la5 S�-�OTi�..lx�rna�� �� ��I� D 3g �U o�Z N1YT
M1ble 1: For small gas arorage (rared inpuJ lcss ihon or equal m 75,000 U�u/hr), electric rvislnnce and hear prunp water hearers, fitr
EnergyFuctar (EF). Fnr fa'gc gns slorage walri htalers (�oled inpul ofgreoler dmn 73,0lM Rttdhr), list Recoorry 6,(frciexcy (REJ,
Thermol Fjficirncy, StandLp L¢�'a' and RoreAlnpue For iusromm�enns gas wu�er lreo�ers, fisi 1hn Tlrerrnnl F'�ciency and Raled Inpu1.
2. Mandamn� Mensures
'1'O COMPLY - ALL BOXES MUST I3E CHECKF,D
�§110-§ I 13: Water heaters, showerhead end faucels are certificd by t6e Calil'omia 6ner�� Commission.
SI50(j): W.�ttt System Pipe and �iank Instd,ilion. And Conling Line Insulalion
I. Storage tank insulation
� A. Storage gas wutcr heaters rnted with an L'nergy Factor no grcuter than the feJeral minimnl standard arc
exmrnally wrapped wilh insulnlion hnving an installcd �hern�al resistanec of R-12 or greater, und
� B. Unfired siorage tanks or othcr indircct hot water mnks huve R-12 extcrnal insulation or RJ 6 intemxl
insulaiion whcre ihe intemal insula�ion R-value is indicated on the exicrior of Ihe tank.
2. Wxter piping and cooling system line insulation thickness and conduetivity
� Fiist 5 feet of hoi and cold wa�er pipes closest w wtiter heater tank, non-recirculating systems, and entire
length of rccirculating seclions of hot wxtcr pipes are insula�ed per Standards Tablc 1 SO-B; and
� Pipe insululimi Por sfenm hyJronic heating s?5tems or hot water systcros > I S psi, It1CCl5 IFie �ey0lremCnLS O�
Standards Tablc 12J-A.
�� Insula�ion is proiccicd from damagc, including that due to suulight, mois�wc, equipment mainlenance, and
wind.
�� I51(flBD: If indicated on Ihc CF-1 R, all hot water pipiog that runs Guut the hot w.ilcr source m Ihc kitchen fixtures is
insulutcd per Standards Table I50-13.
2008 Resrden/ial Compliance h�a'nts A ugtcc/ 2009
INSTALI,A"I'ION CERTIFICA
2 0(
Site Address:
J. Cen[rai Water Healing in F3uildings witli Multiple Dwelling Units (required for prescriptive)
7'O COMPLY -ALI. 60X�S MUST BL CHECKGD
❑ All bo� waler piping in main circulating loop is insulnred lo requiremenls o1� � 150Q)
❑ Cen�rai hoi water systems scrving six or fewer dwelling units which have (1) less than ?5' uf disiribulion piping
ou[doors; (2j 2ero distribution piping underground; (3) no recu�cuiation pimip; and (4} insula�ion on distribu�ion
piping that meeis Ihe requircments of Section I SOQ)
Q Centml hot water systems scrving more Ihan 6 dwelling uniLs - presence of cilher a�ime conu�ol or a
time/tcmperaturc control
DECLARATION S7ATEMENT
• 1 ecnify under penalty ofperjury, unAer the laws of ihe Sia�e of Califomin, Ihe information provided nn this (ortn is true and mrrec[.
• I am eligiblc uuJer Division 3 of ihe Business and Professions Codc W accept rcsponsibility for ronstnatiun, or an nuthoriied
representative of Ihe person msponsible (or constluction (responsible person).
• I certify tlmt Ihe installed fruNres, ma�crixls, componen[s, or manufnetured devices ideniified on [his certificale (Ihe installation)
confoims to all applicable codes and reeula�ionx, a� 8fe irtsiallation is consixtenl wifh thc plarts and speci�cations approved by t6e
enforcement agency.
• 1 revicwed a copy of tite Certifieate of Compliance (CFJ 2J fnrm approved by the enfo¢cment agency that identifies the spedFic
requirements (or ihe installation. I certify thal thc requiremenis detailed on the CI'-I R thut apply to [he inslallation have Ixe� me�.
• 7 will ensure Iha! n eumplrlyd� signed copy of this instatlatiun Certificnle shall he pnsted, or made avaiL�6te with thh building
permil(s) issneA (or Ihe 6uilding, nnd mnde available to [he enforcemen� agency 1'or all applicable inspec�iuns, t undersland
tl�at a signetl cnpy of this Installation Cer(ificate is required to be included �rith the documentation lhc builder pruvides to
[hc boilding uw'ner nt uccupancy.
2008 Residewrtu! Cnmplimice Forma� Angusi 2009
�
NOTls: Lo�v_ri.ve residen�iu/ Luilcling.c e�uhjec/ to �he S�andma/.c nrusr comph, ���ilh u[l app/icabTe niai<iatori, meua•ures li.xle�;
regnrdless of7he compliance npprnach used. Mare slringenl enery,y +uea.��i�res li.r�ed on tfre Cer�ificnle n/�Cnmplimvice (CF-lR,
CF-lR-i1DD, nr Ch'JR-ALT FonnJ.xhofl s��per.rede the irems mnrked widr un a��erisk (') belo�v. ThEa A9nndarory A9eaa�m'es
Smronarv shalf he inca�pornied inlo 7he permit dncwuenis ond �he npplicahleJeanu�e.r sliu!( be considered b�� alI purtiac as mininrtrrrv
componenl peifm�nunce aPeciJicatrona� a�he�leer dvey ure.��hn�vn el re�nbere in Ihe docimrenu nr in lhis siu» mary. Snbmi� �dl �
anoficable seciimi.s o�the M1�-12 Fm�m a�iUr nlon,r.
DESCRIpTION
¢ 1 I fi(a)l: Doors and windows between conditiuucd and unconditioned spaces am manu(acinreA m lim
§116(a)4: Fenesiration pmdums (except field-(abriceted windows) have a label listing ihe certificd U-1
(S{IGC) andi�tfihrationtha�mee[5lherequiremenlso($10-111(a).
§ I t7: Exterior doors and windows are weathervsiripped; nlljoi��ts and penetmtinns are caulked and s�
§7I R(a): lnsulation specificA or installed meets Standards for lnsulating Material. Indicatc type and in
§ I 18(i); Thc thermal cmi4ancc and solar reflmtance vulucs of the cool roofing mare�inl mee�s ihc roqu
a Cool Roof is snccified on thc CF-1 R Form.
'§l50(n): Minimum R-19 insulatioo i� wood-(rame eciling or equivalent U-factor.
§150(b): Loose fill insulation shall conform with mnnufacwrer's installed design la6eled R-Velue.
'y`' I50(c): Minimum R-i3 insutatiou in wood-frame wall or equivaleni tJ-fecmr.
*§ f 50(d): Minimum R-13 insulation in raiscd wood-frame floor or equivalent U-factor.
b150(il: Air re�ardine wrao is [csted. Iabeicd. and ins�alled accordine to AS7'A1 HI677-95(20001 when
on
❑cat
an the CP-IRFarm.
§l50(g): Mandarory Vapor barrier install¢d in Climatc Zones 14 or !6.
§ I50(I): W ater ahsacption ratc for slab edge insulatiom m�teriel elone witho�t facings is no greater than 03°/; weier vapor permenncc mce is no
greater than 2.0 penn/inch and shall be protected from physical damaqc and W IiFJn detenoralion.
Fireplaces, Uecor¢tive Gas Appliances and Gas Log Measures:
§ l50(e)1 A�. Masonry nr faclory-built fireplaces have a closable metal ar glass door coveri�g ihe en[ire opening of the firebox.
§ I50(e)19: Muonry ur faciory-huilt fireplaces have a combusiion outside air intake, whicU is at Icast six square inches in area anA is equipped
with a with a readilv acecssible, opemble, and tiFhpfitting damner and or a combnstion-air co���rol device.
¢ I50(e)2: Continuous bumin� pilot lights and the usc of indoor uir for coo(ing a �rcboxjacket, whcn tliat indoor air is ventcA to thc outside oft
building, are prohibiled.
Snace Conditioniny;, Water Heati��Q and Plumhing SYstem Mcasures:
§I 10-§ I 13: HVAC equipment, water healers, showenc�ada, Taucets and all other regulamd appiianecs are cenificd by the Energy Commission.
§I 1�(c)5: Watcr healing mcimulatio�� loops' serving mul�iple Awelling units anA High-Risc residential occupnncica mect the airrcicase valve,
� I SU(i): Hcating systems arc cqmpped witl
§lSOQ)1A: 9mrage gax walerhealcrs rated
iusu�niion havinK nn instulled Ihei
$150Q)B: Uu6redstorxgct.mkv,suchas:
cxtemal insulation or R-IG inte
§ I SOQ)2: First 5 feet of hot and cold water
�fhnl wnlerpipes ure insufalcd i
§I50(j)2: Coolmg system piping (suction, �
shall be insulatcd to Tablc ISD-I
§1SOQ)2: Pipe insulation for s[cam hydron
§I SOQ)7A: Insulatiai is pmtccted Gom dai
§150Q)3A: Insulalion 1'ar chillcd wxter pip
10U9 Re.ridentinl Convplinnce Fnrms
6as: tan-rype centcal lumnces, liouscltoltl cUoKmE appltances (u(�j�lmnce5 wrtll �It
Ulatcd ui aCCotdancC w1f1� AJHI(FlC, JMAClYA Ot A(,LA.
ermostats thN mcei the se�baek rcyuirements af Section 1 l2(c).
!h en Energy Factnr no greatcr [hsn the fcder¢I minimal sYnndard �n�e cxternatly wrnpped wittt
I resiztance o( R-12 or greater.
age tanks or backup mnks for solar wntcrheaGng system, or other indirect hol water tanks have R-12
I insulalion wherc Ihe internni ins'ulntion Raaluc is indicatcd an Nic cxtctior o1'thc �ank.
es closest to walcr hwtcr tank, non-recirculating systcros, nud cntire lenglh of recircnlating sce�ions
Siandards Tabic 150-8.
led wntcr, or brinc liues),and piping insulated bchveen hcating sourcc and indirae hol water tank
�d L alion I50-A.
eating syslems or hot walcr sys'lems >IS pxi, meets �hc rcquiremen[s of Standards'P. ble 123-A.
le, irtctuding that due m stmlight, moisiurc, equipment maintcnancc, mrd wind.
aod refrigerant suction lines indudes a vapor retardant or is enclosed entirely in conditioned space.
Ai�gus� 2009
ibTandata
Residential
Sife Address:
�
� d150(iW: Sular
Measures Summa
,Z i
ancUur coilamrs are ccrtitieA bv thc
n�r-�u
(Y:�pc 2 of 3
�ll;rll��:
and Fans Measures:
QI: Alt air-distributioii systan ducu mid plenums installed, aro scaled nnd in,vulnled Iu mce� IHe requiremtntx of CMC Seciiuns GOI, 6D2,
603, GO4, 60� n� S�nndarel G-5; supply-ait nnA reNrn-nir ducts and plcnums arc insula�ttl to a minimum iattalled Icvel of R-4.2 or
cncloscd cntircly in canditiuned space. Openings shull bc scaleA wiih mastic, tapc or oiiier duct-closure sys(em ihnt mccis thc applicnblc
requircmau� of UL 181, UI. I81 A, or UL I SIB or aemsol scalant thot mcos the rcquirements of UI. 723. If mastic or tapc is usect io
vcal opcninKs qrcnler ibm� 1/4 inch the cumbinaYon of mastic and cilhcr mes6 or laoe sLall bc used
i)1: 6uilding cavilics, support platfonns (or uir handlers, anA plenums detined or constructed with maferials wher tlmn scaled sheel inetal,
duct board or Ilexible duct shall noi bc used for cunvcying conditioned air. Building rnvities ond suppon pl;�i(onns may comain ducts.
Ducts instnlled i � cavitics and suppon platforms shall not be wmprcssed to causc reductions in qie ttass-seciionnl area of the ducts
i)2ll; Joints and senms of dun sysicros and �hcir components s6a11 na be scaled wilh clo0� back mbber udbesive duct tapes unless sucli Iape
is used in rnin6ination with mnstic and draw bands.
: Gaviry ventilmiog systems scrving eondicioned xpucc hnve either uuromatic ur rcadily acecssible, mnnunity operafed dnmpers.
: In>ulation shall be prolected from dnmage, including �hat duc �o sunlighl, moisWre, equipmem maintenance, and wind. Ccllular foam
ins'ulation shnll be protcered as abovc or painied with a coating tha[ is water rctanlant nnd pmvides shielding from wlar ndintio�� tlut
can causc dc�radntion of Ihe matcrial.
0: Flexible ducts cannot have Oorous inner cores.
All dwelling units shull meet �he requimmema of ANSI/ASHRAE Smndard G22-2007 Ventilation and Accep�a6lc lodoor Air Quality in
Low-Rise Rcsidential Buildings. Window opention is not a pertnissi6le mcthod of providing Ilie V✓hole Building Ventilation rcquired in
Section 4 ofthat Standard.
§ I 14(a)�. Any poal ar spa hcating sys�cro shall be cenillcd io have: a Ihcrmal ethcrenry tha
en on-off swikh moun[cd outside o(Ihc heater; a pennonent weathcrproof platc <
electric resistanec heating or a pilM IiAht.
§l l4(b)1: Any pool or spa heating equipmcnt shall 6c installed with at least 3G" of pipe bci
lines, ar buill-up connections (or future solar heatln�
§I l4(b)2: Outdoor pools or spas that have n hwt pump or gas hwter shnll hevc n cover.
§ I 14(b)3: Fools shall have directional inlets that adequately mix �he pool wa�er, and n time
§I50(p): Rcsidentinl
Residcntial Li�h[i
ar
thc n�mn sizine. tlow
d wi[h opemling insiruciions; and shall not use
� fdter and heater, or dedicuud suctiun and mtum
:h �hat will allow all pumps �o bc set or
ond valve muui¢ments of 5150(Dl.
Sink has an efficacy that i� no lower Ihmi the efficacies conmined in
I'ne wniti�gC ul pennnnelt[Iy mstallCtl lumnIDires' Shall bc tletcrtnmctl us spec�tic(I uy g Uu(tlJ.
Rallasta for 1luoresccnt lamps raicd l3 Watts or grcala sh�ll bc deco�nnic nnd shall have an uutput Gequenry no leas thnn 20 kFlz.
Pennancntly insiNlcd night Iighis nnd night IigMs intc�'al lo a pcnnancnlly inslallccl luminairc or exhaust fan shall wnluin o�dy high
efficacy lamps mccling the minimmn elTsacics wmnincd in Tn61e ISAC and xhnll not con�nin a line-voltayc socket or Iine-rultugc
lamp hoider, OR shall he rntcd to consume no more tlian fivc watts ofpower as deicnnined by (130(d). and shal! not contai2 a medium
§750(k)G: Lighiing inlegml lo exhaust fans, in rooms olher than kitchens, shall mcet ihe upplicnblc requiremeNs af $ I50(k).
§150(kp: All swilchiog devices nnd controls shall mee� Ihe mquircmenis af § I50(k)7.
§7 50(k)R: A minimum of 50 percent of �he w�nl raled wattuge of pernianently� insqJled lightu�g in kilchem slmll be high c(ficacy.
EXCEPTION: Up �u 50 w•ata (or dwclling units Icss lhan or eyunl ro 2,500 f�3 or 100 wans for dwelling uni�s largcr Ihan 2,500 f�° may be ezeinpt
fmm ihe 50% hig6 efGcncy requiremenl whCn: nll low c(ficacy luminaires in the kitchen nm coNrolled by a manunl uu uccupanl
scnsor, dimmcr, cnerbry managcmem systcm (EMCS), or o multi-sccne pmgnmmable contmi system; ond oll pcnnnnuitly insialkd
lumivaries in garages, laundry r0oms', clozcfs grcater Ihnn 70 squnm I"ecl, :md uti(ity ruoins arc high C(ficncy mid cumrol led by n
manual,un occupantscnsor.
§ I50(A)9: PConanently instnllcd lighling Ih:tl is iulcmal to cabinets shall usc no nmrc Ihun 20 waus of power per linc�r foot of ill4ininatcd
cabinci.
§ I50(A)10; Permnncntly insmlled luminaires in bathmoms, auached and AcmcheJ qnmges, luundry rooms, cluseis and utility rooms shall bc high
1008 2eside�rtiaf Complinnce Fbrms �l ugu.q 2009
Mandator}� Measures Summar}� MF-iR
Residential (Pa��e 3 of 3
tiileAddress: ' IinfurcementAgenc�� I Date: �//��/J
� ���, 1�n,Y�i1h?. \n�(ll� i�nC�'ft, IJ1,.�n ';
F;XCEPTION 1: Pcnnanenlly inslallcd Inw cfficncy luminaims shall be nllowcd provideA that ihey are conirolk� by o m�mual-un
uccUpantsensorcciiificdiucomplywilhlhenpplicahlerequimmentsof §11).
EXCEPTION 2: Pennanenlly installed low e(tieucy luminnire> in cluseis Iess Ihan 70 square ket are uo� requimd Io be cuNrolled 6}' �
1: Pennanenlly insealled luminaires IocaieJ in rooms or arcas otlier Ih:m in kiichcns, bathrooms, gmages, laundry rooms, cluseis, nnA wiliiy
rooms shall be high cfLcaey luimnaires. �
EXCGPTION 1: Pcrmanenily insinllcd low cffiwcy luminaires shall bc nllowed providcd they ure controllcd by cithcr a dimmcr switch
that complies with Ihe npplicable requiremenls of § I I Q or by a manual-on accupani sensor that camplia with 11rc
applicable rcquircmcros o( ¢119.
{iXCEPTION 2: Ligh[ing in detached storngc building less tlmn 1000 >yunrc fe<t bcatcd on a res'idenlinl silc is nut myuirod 10 cumply
with $I50(k)ll.
2'. Luminaires recessed into insulatcA ceilings shall be lisfid for zero clenranec insuiation contaa QC) by (.lnderwrilcrs Lnboraeodes or
other nationally rccognized trsting/mting labomrory; and have n labcl that cenifics the lumiunaire is ainigh� with air Icakabe less then
2.0 CFTd at 75 Pasents when lesmd in accord�nce with ASTM E283; and 6e senled with n gaskei or caulk beiwcen the luminairc housing
nnd ccilin�;. � �
3: Luminaires providing outdoor lighting, including lighting for privnte patios in low-rise resiAential 6uiltlings with four or more dwclling
miits, entranrex, balconies, and porches, whieh are pemionentiy monNed to a residential building or to other buildings on Ihe same lo�
shail bc l�igh e�cacy.
F'XCEPTION I: Ycrmanently inatalled outdoor low efficncy luminaires shall bc allowed provided thiu Ihcy arc ron�rolled by a manual
odoff switch, a motion sensor no[ having an override or bypass swimh Ihat disables thc mo�ion scnsor, and one oF Ihc
following controls: n phoroconirol not having nn override or bypass switch ihat Aisables the photocuntrol; OR an
astro�omical time clock not hnving an oveRide or 6ypass swimh that disables thc astronomiwl time clock; OR an
aiergy maoegement mnirol systcm (EMCS) not having an ovcrride or bypass switch thnt allows the lumiuui`e to t�e
always an
LXCL'PTION 2: Outdoor luminaires used to comply witli Exceptionl to § I50(k)I3 may be controlled by a temporary ovcrride switch
which 6ypasses the motion sensing function proaiAed Ihal the motion unsor is automalically rcactivated within s'ix
hours,
EXCEPTION 3: Pemianently installed luminaircs in or around swimming pool, wuter features, or other locatiun subject [o P.nicle 680 uf
the Califomia Elecvic Codc necd not bc hieh efficacv luminaires.
not conWm a screw-W5e sockel, ana coRcume no morc
Lightlng tor parkmg bts and carpons wrth a total of for 8 or more veh¢Ics per stle shall compty wilh the apphcablc rcqmrements m
Sections !3q i32, 134, and 14Z Lighting fur parking garoges for 8 or more vchicles shall comply with thc applicable rcquircmenis of
Sections 130, 131, 134, and 14G �
PertnanrnNy installed lighting in the enclosed, non-dwelling spaces of 7uw-risc residential buildings with four or more dwe)ling imits
shall be hiyh efficacy Illminaims.
IiXCEPTION: Pennanently inswlled luw efY�c�cy luminaires sh�ll be allowed provided iha� (hcy are conlrolicd by an uccupant sensor(s)
certificd ro comolv wilh ihe aoolicable reouiremenls of 6� �9.
2008 Hesidenlin! Compliance Form.s Auyus! 20(19
• CITY OF COSTA MESA � � �
O�p MFS ` � ' sunn�N� o�v►s�oN � � � -
F`�� 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Faz (714) 754-0856 • www.ci.costa-mesa.ca.us
� FOR INSPECTIONS CALL: (714) 754-5626
�"'°"°"°'� PERMIT NUMBER: M09-00122
PERMIT TYPE MECH
APN: 93405088
JOB ADDRESS: 627 DANUBE DR CM
Vicinity:
SQ. FT: 0
STATUS: ISSUED '
DATE ISSUED: 1 211 6/2 0 0 9
ISSUED BY: KJB
Suite/Unit:
SCOPE OF WORK: REPLACE FAU AND A/C UNIT. A/C UNIT IS INSIDE THE DWELLING. NO HOA LETTER REQUIRED.
OWNER:
PHONE:
APPLICANT:
PHONE:
Address:
Ciry/State:
ZAMBON, NICHOLAS
71a�0a-635a
JACOBY, ERIC
SERVICE CHAMPIONS
22917 SAVI RANCH PKWYUnit:
YORBA LINDA, CA ZipCode: 92887
MECHANICAL PERMIT FEE SUMMARY
MECH ITEM FEE: $53.00
PLAN CHECK FEE: $0.00
INVESTIGATION FEE: $0.00
REINSPECTION FEE: $0.00
TOTAL FEES: $53.00
Address: 627 DANUBE WAY Unit:
Ciry/State2ip: COSTA MESA, CA
Address: Unit:
City/State/zZip:
License No. 799770
PHONE: 714-777-7777
CELL:
%''-l;71 �='
' I,•Fp.
. ^ i 7'a
NOTICE: The work authorized by this permit shall comply wilh all applicable handicap access requirements under Califomia statutes and related
regulations. (Ord. No. 92-28, § t, 72Q1-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authonzed under this permit to be considered legal, such work must comply with afl appficable codes, and alt
required inspections and final approval must be obtained. Failure to oblain inspections and fnal approval vrill result in the expiralion o� [his permit.
CO�Ef. INSPECTONTYPE UA7E INTITIRL LOOEt INSPEC110NTPE DATE � INRIIAL
1816 Fixed System Final Fire Prevention 206 Final Mechanical I-[�� ��.,1
1266 Pool Spa Final 208 Final Plumbing l
200 Final Re-Roo/ 210 Final Elechi�yl
201 Final Block/Relaining Wall 212 Final Fire Pr¢vention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Si�e
204 Final Demoli�ion 250 Finai Building/Occupancy
WORKERS' COMPENSA�iION DECLARATIO�
I hereby aKrm under penalty of perjury one of the following declarations:
❑ I have antl will maiNain a certifcate ot consent ro selt-Insure for vrorkers'
compensation, as provitletl for by section 3700 of Ihe Labor Code, for the
performance of t�e vrork for vuhich this permil is issued.
heve and will maintain workers' compensation insurance, as required by
ion 3700 0! the Labor Code, fw the peRortnance af the v.ork fw which [his
pertn t is issued. My workers' compensation Insurance carrier and policy
number are:
�ri„�.../�lA-�T£STi �
(inis seGqn need rrot be wmple(ed ntne peimA is valuetl at one hundretl dollais (St00) or less )
�,: C�2�� Fl6�f � 7SD"�
❑ I ceAify that in the per(ormance of the vrork for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to the workers' compensation lavrs of Calitomia, and agree iha[ if I should
become subject to the warkers' compensation provisions of Section 3700 0!
the Labor Co . I shall forthvrith wmply with these provisions.
o` wm'� i nature 7/ Da �/
WARNING: FAILURE SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLL4RS
($10U,000�, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR W SECTION 3706 OP THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrm that I am licensed under provisions o( Chapter 9(commencing
with Section 7000) o( Division 3 of the Business antl Professions Code, and
my license is in full force and eRecl.
�•`�. _.. -`s:r:�r.l'iZd
�v/it/ag
Go•�[a�ad_a•c�o� ' �..- Date „
CONSTRUCTION LENDING AGENCY:
❑ I hereby a(frm that ihere is a construclion lending agency for the
pedortnance of lhe vrork for wfiich this permit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Adtlress:
SignaWre
OW NER•BUILDER DECLARATIONS:
I �ereby aKrm that under penalty ot perjury that I am EXEMPT PROM THE
CONTRACTORS LICENSE LAW for Ihe following reason (Sec. 7031.5,
Business and Professions Code: Any ciry or counry which requires a permit to
constmct, alter, improve, demolish, or repair any structure, prior lo its
issuance. also requires the aDPlicant for such permit to file a signed statement
that he or she is licensed pursuaN to the provisions of the Convactors
License Law (Chapter 9(commencing with Section 7000) of Division 3 0( the
Business and Pmfessions Code) or thal he or she is exempt therefrom antl
Ihe Dasis for the alleged exemplion. Any violation o! Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more [han
five huntlred tlollars (5500).):
❑ I, as ovmer of the property, or my employees with wages as their sole
compensation, WILL DO THE WORK, and the struclure is nol intended or
oflered for sale (Sec. 7044, Business and Professions Code: The Contrac[ors
License Law does not appty to an ovmer of property who builds or impmves
thereon, and who does such vrork himself or herself or through his or her own
employees, provided that such improvements are not intended or oftered for
sale. If, however, the building or improvement is sold within one year o/
completion, the owner-builder will have the burden of proving that he or she
did not builtl or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CON7RACTING WITH
LICENSED CONTR4CTORS to construc� the projecl (Sec. 7044. Business antl
Professbns Code: The contractors License Law dces not appty to an ovmer of
propetly who builtls or improves thereon, and who cont2cls for such project with
a contractor(s) license pursuant tothe Contractors License Laws.�.
❑ I am exempl under sec.
Business and Professions Code for this reason:
3on-as �vov�
Ovmer ID venfied by tlriver•nse. ❑ Yes ❑ No
Driver's License No. ` Expires:
Verifcation of Ownership by (type o! document, i.e. - property [ax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no encavation frve (5) or more feet in depth into wfiich a
person is required to descend, will be made in connecl'an with wnrk authorized
by �his permil, and that no building sWCNre, sc�fdding, falsework, ademolilion
or dismantling thereof, will be more Ihan Ihihy-six (36) feet high. (Chap. 32, Gry
2, M 2, Sec. 341, Title 8, Califomia Administrative Cotle).
❑ As owner-builtler, I will not employ anyone to do vrork which would
require a permit from the Division of Industrial Safety, as noted above, unless
such person has a permit to do such vrork from the division.
Apdiwn(s SignaWre
Division of Intlustnal Safety Permit Number: _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicanl or preseM or fuNre building occupant need to (le and
certify a Business Plan (or emergency response to release or threatenetl
release o( a hazardous material? ❑ Yes ❑ No
(Section 25505 0( the Califomia Health antl Safety Code requires, with some
exceptions, thal 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 quanliry of hazardous materials equal to or grealer than a weight of
500 pounds. or a volume of 55 gallons, or 200 cubic teet of compressed gas
at standard temperature antl pressure).
2. Does or will the appliwnl or present or future building occupani need to file
a registration fortn (or acutely hazardous matenals? ❑ Yes ❑ No
(Section 25533 ot the Califomia Health and Sa(ery Code, with some
exceptions, requires regislration with the Costa Mesa Fire Department by
each business which at any one lime has on hand a quantity of acutely
hazardous matenals equal to or greater than a weight o! 500 pounds, or a
volume of 55 gallons, or 200 cubic feet o( compressed gas al stantlard
temperature and pressure�.
3. Does or will the applicant or preseM or future building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Seclion 25534 of the Calitomia Health and Safery Code provides thal the
Costa Mesa Fire Department may require Ihe preparation, certification and
fling vrith the Fire Department of an RMPP by businesses which are required
�o register acutely hazardous materials with the Fire Department.
4. If an RMPP is presently required, has Section 25534 of the Califomia
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will Ne applicant or present or fulure builtling occupant require lor
ihe work which is the subject of ihis application a permit for such construclion
or modifcation from the Soulh Coast Air Quality Management District or Irom
any other air polWtion control tlislrict or agency? ❑ Yes ❑ No
(Section 658502 of the Califomia Govemment Code requires that the requested
infortnation be fumished on applications ta non-resi0ential building permits).
6. Will any pah of the faciliry to be constructed under Ihis permit be within
1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
Qf "yes", the facility must meet the requirement of Sections 25534 and 42303
of Ihe Califomia Health and Safery Cotle).
7. If a pertnit from Ihe South Coast Air �ualiry Management District or olher
air pollution control district or agency is required for the vrork which is the
subject of this applicatioq have all of the disclosures prescribed by Califomia
Health and Safely Code Seclion 42303 been made? ❑ Yes ❑ No
8. Qf 'yes", attach certifcate of compliance fmm the appropriate air polNtion
coNml oKcer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty ot perjury the
information given above is cortecL I agree to comply with all stale laws antl
city ordinances regarding Hazardous Materials antl Emissions.
SignaWre oaie
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certi(y under penalry of perjury that I have read this application and state that
the information given is correct I agree to comply wiih all state laws antl city
ordinances relating to building construction, and authorize representatives of
the City o( Costa Mesa lo enter upon the above-described property tor
inspection purposes. I agree not to occupy or allow occupancy of any building
aulhorized by this permit until final inspection.
Sgnal eolle I wner�s) Dale
/ "7�i � ��_
— �'A� tlMppJ�an�� Date
Stratz Permit S�rvice - HVAC - Residential
,
PROPERTV DRqWING
Click on the map below ro open a new wintlow which will allow you ro place a mark where [he A/C unl[ will be
placed:
Property Line
Back Yard
2��
20' --
PL
FrontYard
Please describe any properry line barrier which exists:
Barrier type: 0 heighd 0
If gate or bushes exis[s in side yard ro screen uni[, describe:
Ga[e or eushes: Yes � heighC 0
� z7 Q� N vg � w.� ��
nlotes:
( s,�� u„�ses �
close winaow
Page 2 of 2
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CITY OF COSTA MESA
PLANNING n1�'�c�n�.i
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OR CORRECT!(lhS •� '
APPROVED BY TH{i PI.:�N�� • � �
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http://adminstratzpermit.com/Stratz/Admin/.TobH V AC.aspx?Job1 D=2763&JobTypel D=2... 12/15/2009
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' 38.1.0
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA. CALIFORNIA 92626
BUILDING � r"� "
ApORE55 _
pWNER HELTZER ENfERP
MAIL
ADDRESS 740 N. La Bre
ciT� Los Angeles, CA
CpNSTRUC'fION
LENOER United Cal
BRANCH Main Branch
aaoAess 600 S. Sprine
ARCHITECT �. _ . . ,...
�
NO.
TEL.
man uo.6
e. Bever
CONTRACTOF GeorQe J. Heltzer
ADDRESS 740 N. La Brea Avenue
TE�.
arv Los Angeles, CA 90038 No.937-2171
� c No. 3144 uc�Na.
SIZE NO.OF B�DCS.
OF �OT I NOW ON LOT [�]pRe
� -, �.:,�,�.�
APPLICATION FOR SUILDING PERMIT
'[iVED BV ❑ATE 9ECEIV6D n�re icc���
TRAC7
�
OWNER
FIRE
ZONE
APPROVED
�lE NO.OF
3-�� P�� ;
VARDS APPROVED
MAIN BUILOING
1
� SIZE OF NO.OF e'
Z NEWBIDG. ROOMS STORIES 2 L.SI�E i?FT.
a EXYERIOR WAL ROOF
V COVEFING �laster COVERING� WOOd REAR ZQ FT
J USii OF BU}LO�NG AND WORK TO BE PERFORMED pISfANCE BET.
� Residential � MAIN B�DGS.
1
Q �L i VAR. #E �j
� Cf �✓ S �•C LLC C.U.P.# C� ��
— APPROVED
n
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�
, I �ereby acknowledge cha[ I hava reetl this aOP���ation antl scaie
� (hat iha above infprmation is cOrrect antl aB�ae to comply with
� all laws regulacing buildine consttuciion, antl I shall not employ
any Perwn in viola[ion of the warkmen's compensation laws of
q cha S[aro of California. � O
� 1 hefehY certity i�at 1 am O��Per1Y �icensetl a: a contreciot untle� $Q. FT.
[he State ot California Businass antl P�otessions Code, DivisiGn 3, THE AMOVNTSH
Chnpaer 9, a�d rnex s�ch licenses a.e In �wl forca antl ettect, or I THE PVRPo6E OF I
am Bxempi trom the provi 'ons of tha State of California Business yALVATION
antl Profassions Cotla, Divi yn 3, Cnapser 9.
s� �n�,,.a e, �! - g! li L G �
re.mittee /' -v'��� ' G �
Aucnori:ed Agent
P
LOT
USE OF NEWG C`;��'p`�
BUILDING � � �.Z
VAROSAPPROVED
ACCESSORY 9llILOING
FT
BET. MAIN &
ACCESS. BLDCS.
DATE G
APPROVED ,1 �.
m
273a �.�2_ o
7WN VNDER VAIUATION IS FOR
STABLISHING 4 PERMIT FEE ONLV: m
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LL