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Home My WebLink About650 DARRELL ST - Building Permitsv\ ' i � � CITY OF COSTA MESA � BUILDING DIYISION 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax Q14) 754-4856 • www.ci.costa-mesa.ca.us PERMIT TYPE; B_COMBO Sub Type: RES_ALT �06 ADDaess: 650 DARRELL ST CM APN: 42215216 Vicinity: Canst Type: V-B FOR INSPECTIONS CALL: (714) 754-5626 Zoning: SQ. FT:. 499 PERMIT NUMBER: BC09-00130 STATUS: DATE ISSUED: ISSUED BY: Suite/Unit: ISSUED 08/31/2009 �" �Primary Occ:' R-3 � . Valuation: $46,107.60 SCOPE OF WORK: 78 SF FIRST FLOOR ADDITION AND 570 SF ADDITION ABOVE AN EXISTING GARAGE. 2 BEDROOMS W ITH 1 BATHROOM AND LIVING ROOM. ELEC: 5 LIGHTS, 10 OUTLETS, 10 SWITCHES, 1 SUBPANEL TO 200A, 1 METER TO 200 AMP;.1 INST RELOCATE RECESSED WALL HEAT � �� ' - - - 1 SHOWER AN� 1 TOILET 1 SINK . � � - - . - ' � "PLNG - 4 BR AND 1 DEN TOTAL. INSPECT PER APPROVED PLAN: EXISTING W.FI. IN GARAGE,'EXISTING F.A.U. BY LIVING ROOM, ONE DOOR FROM GARAGE AND ONE 4.5 FT. W IDE OPENING FROM FIRST FLOOR INTERIOR TO FIRST FLOOR ADDITION (NO �XTERIOR ACCESS), AND ONE WASHER/DRYER BEHIND STAIRCASE FOR THE SFR'" �, OWNER: ULLOA, WCIO SOLIS Address: 650 DARRELL ST -. - � Unit: Phone: City/State/Zip: COSTA MESA, CA � , - APPLICANT: VERA, ALFONSO Phone: 909�771-6368 CONTRACTOR: OW NER-BUILDER Phone: Cell: ARCHITECT: ENGINEER: BCP ENGINEERING Address: City/State/zZip: � Address: Unit: , . City/State: � License No. License No.0065593 COMBINATION PERMIT FEE SUMMARY Building Plan Check: $399.07 Building Fees: $613.95 Electrical Fees: $8�.50 Mechanical Fees: $38.30 Plumbing Fees: $49.25 SMIP Residential: $4.61 SMIP Commercial: $0.00 Bldg Std Admin Fund $2.00 TOTAL FEES: $1,188.68 "Refer lo (ee receipls for all fees paltl for project License No. 000000 Unit : ZipCode PHONE: PHONE:909-215-5071 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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiretion of this per CODEN. INSPECTIONTYPE DATE IN➢11R15 CODEN INSPECTIONTYPE DATE IN ALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical LZ 23 ' 126fi Pool Spa Final 208 Pinal Plumbing — 'L—_3 /�i 200 Final Re-Roo( 210 Final Electrical /G/7J3 I 7 rT""'" __r` 201 zoz 203 204 Final Block/Retaining Wall Final Factory Fire Place Final Sign Final Demolition 212 220 Final Fire Prevention Final Planning Approval 222 Final Site 1�'�T� V 250 FinalBuilding/Occupancy . ,. - .a • WORKERS' COMPENSATION DECLARATION: I hereby af5rm untler penalry of perjury one of Ihe following tleclarations: ❑ I have and will maintain a certificate o( consent to self-Insure for workers' compensation, as provided (or by section 3700 of the Labor Code, for the peAormance of [he vrork for which Ihis permit is issued. ❑ I have and vrill maintain vrorkers' compensation insurance, as required by section 3700 of the Labor Code, for the peAormance of Ihe vrork for which this pertnit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (This secliwr need nol �e comdeteE R fhe pemuf u valueE at one huntlretl CWlars (5100) w less.) Policy Number: ❑ I certify that in [he peAormance 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 laws of Califomia, and agree that if I should become subject to the workers' compensation provisions o( Section 3700 of the Labor Code. I shall forthwith comply with these provisions. Appliwnfs Signature Dale 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, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrm that I am licensed under provisions o( Chapler 9(commencing with Sec[ion 7000) of Division 3 0( the Business and Pro(essions Code, and my license is in full force and e((ect. Lic. # Class # Gonlraclors Signalure Dale CONSTRUCTION LENDING AGENCY: ❑ I hereby aKum that Ihere is a constructan lending agency (or Ihe peAortnance of the work for wfiich �his permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Adtlress .. SignaWre oate OWNER-BUILDER DECLARATIONS: I hereby affrm that untler penalry of perjury that I am EXEMPT FROM TME CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any ciry or county which requires a permit lo construct, alter, improve, demolish, or repair any sWcture, pdor to iIs issuance, also requires the applicant for such pertnit to file a signed statement that he or she is licensed pursuant to the provisions of Ihe Contractors License Law (Chapter 9(commencing vrith Seqion 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom antl the basis (or the alleged exemption. Any violation of Seclion 7037.5 by any applicant for a permit subjects the applicant lo a civil penalry of not more than fve hundred tlollars ($500).): I, as owner of the property, or my employees with wages as their sole � compensation, WILL DO THE WORK, and ihe stmcture is not intentled or oRered for sale (Sec. 7044, Business and Pmfessions Code: The Contractors License Law does not appty to an ovmer of property who builds or improves lhereon, and who does suc� work himself or hersel( or throuqh his or her own employees, provided that such improvements are not intended or oftered for sale. If, however, the building or improvement is sold vrithin one year of wmpletion, 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 o( lhe property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct ihe projecl (Sec. 7044, Business antl Pmfessions Code: The contractors License Law dces not apply to an owner of property who builds or improves thereon, and who coN2cts for such project with a cont2ctor(s) license pursuant ro the Contractors License Laws.). ❑ I am exempt under sec. Business antl Professions Cotle for this reason: _�� i�c�c— ' 3r/� Sg^awrr-c„ Da�e"`r- _ JOS)-46�3I0]) �" � � � � 1 ' � Owner ID verifed by driver s license.�es ❑ No Dritver's License.No. ��,/ /�} F�cp„ iresr Verifcation of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUS7RIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certdy that no eacava[ion (rve (5) or more teet in tlepth into vfiich a person is required to descend, will be made in connectbn with wnrk authorizetl by this permit, and that no building structure, scaffoltling, falsewnrk, a demolilion or dismantling Ihereof, will be more than thirty-six (36) feet high. (Chap. 32, Grp 2, Art 2, Sec. 341, T�le 8, Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to tlo work wfiich vrould require a permit from lhe Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Apvlicant's Signatore Date Division of Industrial Safety Permit Number HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or fuWre building occupant need to file antl certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Seclion 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be fled 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 fuWre builtling occupant neetl to file a registration form (or awlely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Sa(ery Code, with some excep[ions, requires registration with [he Costa Mesa Fire Depariment by each business which at any one time has on hand a quanlity of awtely hazartlous materials equal ro or grealer than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard cemperaWre and pressure). 3. Does or will the applicant or present or fuWre builtling occupant need to prepare an RMPP (Risk Managemen� antl Prevention Program for acu[ely hazartlous ma[erials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safery Cotle provides that the Costa Mesa Fire Department may require [he preparation, certi(cation and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No S. Does or will �he applicant or presen� or (uNre builtling occupanl require for the vrork which is the subject of this application a permit for such construction or modifwtion from the SouN Coast Air Quality Management District or trom any other air pollution control disMct or agency? ❑ Yes ❑ No (Sectbn 658502 0( the Califomia Govemment Code requires that the requestetl in(ormation be fumished on applications fa rwn-residential buildinq pertnits). 6. Will any part of �he facility lo be constructed under this permit be within 1000 feet from the outer boundaries o( a school? ❑ Yes ❑ No (If yes", the facilily must meet the requirement o( Sections 25534 and 42303 of the Califomia Health and Sa(ery Code). 7. If a permit from the South Coast Air Quality Management Distnct or other air pollution control district or agency is required for the work which is [he subject of this application, have all of the disclosures prescribed by Califomia Health and Safely Code Section 42303 been made? ❑ Yes ❑ No 8. Qf "yes", attach certificate of compliance trom Ihe appropriate air polWtion control oKcer). CERTIFICATE OF COMPLIANCE: I certify that under penalry of perjury the information given above is covect I agree to comply with all state laws and city ordinances regarding Hazartlous Materials and Emissions. SignaWre Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have reatl this application and state that the information given is cortecL I agree to comply with all state laws and city ordinances relating to building conswction, and authorize representatives of the City of Costa Mesa to enler upon ihe above-described property for inspection purposes. I agree not to occupy or allow occupancy of any builtling authorized by this permit uniil �nal inspection. �� SignaWrea�lLe�yga�lOvm�eqs) Oa�e -0YV'77 V ^ ' � AnElorAulM1Oriz2CAppli[anl "'�- ale•, : ., ..... , ;_,� . r��;�,. s NEWPORT-MESA UNIFIED SCHOOL DISTRICT � � os 3� ��t��1-�q��,,_ .. ....... � Q.Y , F,��°`�'``'�`��',r: �; 001�#3Q'?OI��"�r °a; ' .�l�_693'S'-...:,, _ CER7IFICATE OF COMPLIANCE Of DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: ( �Cily of Costa Mesa ( ) City ot Newport Beach ( ) County of Orange �A plicant: F� �� C�� Address: �SS -Q/�' �I�,LJ.— � � I �(� 9� �--� �a � �o� Telephone Number: TracUParcel and Lot Number(s): l�'� �C �Z — l� Location ot Project: Number of Square Feet o(: Residential Space Commercial and Industnal Space CommerciaUlndustrial Projed is: (Check One) Warehouse R8D _ Movie Theater _ Mini-storage _ Neavy IndusUial _ Regional Shops _ Light Industrial This project is exempt because � SZ� __S��L!—x E1.84 x E .30 _ Motel Bank _ Neighborhood Shops _ RacqueVHealth _ Hotel Medieal Office O(fice Park District Receipt No. Plan Check I�e � �G�3D �� z 3� Total • Total Preschool Auto Repair Hospital Large Otfice 016ce Bldg. Restaurant Fast Food ?his certifies that the above-named Developer/Applicant has paid school haa6ty fees in comptiance with Government Code sections 53080 and 65995. The Building Pemiils for this square footage in this proposed development may now be issued by your jurisdic5on. Checks are to be made payable to NewpoA-Mesa Unified School Disfid. By The above representatlon as to square footage is true. Appticant agrees that if it is later determined that such representations are not true, then this certificate shall automa0cally terminate and the appropriate Cily/County shall be notified. �"` �/�/'o� Date: �5�� 1�1�J� �ty of Costa �lesa Bu� ing 1�ivisioia 77 Fair Drive, Costa Mesa, CA 92626 714-754-5273 / Fax 714-754-4856 {�HdlV�fi 9��['� ��I��i�r�� Permit# /✓C.C/9'0�l� Disctosures & Forms for Owner- Builders Appiying for Construction Permits IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner; An application for a building permit has been submittg� in your _ e listing yo,y� r elF as he builder of the property improvements specified at l J C� ��. �1� � We are providing you with an Ov✓ner-Builder Acknowledgment and Informzticn Verification Form to mzke you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, lhe property owner, obtain lhe prior approval of lhe permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each sta ement below to signify you understand or ver!fy fhis information. f^�4. I understand a frequent practice of unlicensed persons is to have the property owner obfain an "O�a�ner- Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious tinancial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting 25 an Owner-Builder and am av✓are of the limits of my insurance coverage for irjuries to workers on my prcperty. �S. I understand building permits are not required :o be signed by property o�a�ners uNess ?hey are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. �°S3. I understand as an "Owner-Builder" I am the responsible party of record on the permiL I understand that �I-may protect myself from potential financial risk by hiring a licensed Contractor and having fhe permit filed in his or her name instead of my own. S 4. I understand Contractors are required by law to be licensed and bonded in California and ro list their icense numbers on permits and contracts. �5- I-understznd if I employ or otherwise engage any persons, other than California licensed Contractors, an'd the total value of my construction is at least five hundred dollars (5500), including labor and materials, I may be considered an "employer° under state and federal law. ��6. I understand if I am considered an "employer" under slate and federal law, I must register vrith the state and'federal government, withhold payroll laxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my faiiure to abide by th�se laws may subject me to serious financial risk. �7:,I.understand under Califomia Centractors' State License Law, an Owner-Builder who builds sing!e-family re`sidential structures cannot legaily build them with the intent to offer them fcr sale, unless all v;ork is perform=d by licensed subcontractors and the number of structures does not exceed four within any czlendar year, or all of the work is performed under contract with a licensed general building Contractor. �8. 1 understand as an Owner-Builder if I sell the property for which this permit is is;ued, I may be held tiable � or any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defecls in the workmanship or materials. 1 of 2 � � � � . . , � �9:'I''understand I may obtain more information regarding my obligalions as an "employer" from the Internal Revenue Service, Ihe United Stafes Small Business Administration, the California Deparlment of Benefit Payments, and [he California Division of Industrial Accidents. I also undersland I may conlact ihe Califomia Contractors' State License Board (CSLB) al 1-800321-CSLB (2752) or www.cslb.ca.gov for more informalion about licensed contractors. �t0�i am aware of and consent to an Owner-Builder building permit applied for in my name, and understand lhat I am the party legally and financi211y responsible for proposed con=?ruc!ion 2ctivity 2t lhe (ollot:�ing 2ddress: �1:t: I agree tha�, as the parly legally and financially responsible for this proposed conslruclion aclivity, I v;ill abide by all applicable laws and requiremenls that govern Owner-Builders as tivell as employers. ��12. I agree to notify lhe issuer of this form immediately of any additions, delefions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed lo protect the public. If you contract wilh someone who does not have a license, lhe Conlractors' Stale License Board may be unable to assist you wilh any financial loss you may suslain as a result of a complaint. Your only remedy againsl unlicensed Contrectors may be in civil court. It is also important (or you lo understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held lizb!e for damages. If you cbtan a psrmit as Oe.rer-Duilder and wish to hire Ccntractcrs, ycu will ba raspor�;ible for verifying whelher or not lhose Contractors are properly licensed and the status of their workers' compensation insurance coverage. � � Before a building permit can be issued, this form must be completed and signed by the property owner and retumed to the agency responsible for issuing the permit. Note: A copy of the-propeRy,ownec'� �d�iver.'s=license�lorm notarizatron, or other veri(ication accepfable ro the agency is required to be presented when ihe pe�mit is issued to verify the prope�ty owner's signature. Signatureof_properfy;oyner �U['�� o��s D2te: � �� ^JOic: TiiE fviiG'v'vifi� nULiG�lZa'ii0i"7 �Gi(17 IS icQUiiB(i i0 u`B GVllijlleied `uy i!'ie prope�iy uwiiBi uniy tvli?n designating an agent of ihe property owner to apply (or a consfruction permit (or the Owner-Euilder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibitity, I hereby authorize the following person(s) lo act as my agent(s) to apply for, sign, and file the documents necessary to oblain an Owner-Builder Permit for my project. Scope of Construction Project (or Descriplion of Work): Project Location or Address: �('��« j � CJ� ti{,t� a� L,Q, g�� Name of Authorized Agent: ,A �,.�gp (/Yr� Tel Nor��%� ��-��(�Q3� Address of Aulhorized Agent: � �,��j_�� I declare under penalty of perjury lhat I am lhe property owner for lhe address lisled above and I personally filled out the above information and certify its accuracy. �Jole: A copy ct;he o�vnar's driver's license, fornt notarization, or other veri(cation acceptabfe to ihe agency is required to be presented when Ihe pem�it is issued to verify the propertyowner's signature. P_cop'e`rfy�Own`er's•Sig`naWce: � � C�� .J�� Dale: " jo �' � _. 2of2 � � • CITY OF COSTA MESA Y""' BUILD/NG DIVISION . ,, � r � 77 FAIR DRIVE, COSTA MESA, CA 92626 • Q14) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us �.��'� fi. FOR INSPECTIONS CALL: (714) 754•5626 PERMIT NUMBER: B09-002�0 PERMIT TYPE B ROOF2 STATUS: ISSUED APN: 42215216 DATE ISSUED: 11/02I2009 = - -ISSUED BY: KJB JOB ADDRESS: 650 DARRELL ST�CM "' ;- ' Suite/Unit: _ Vicinity: RESIDENCE � Squares: 1200 Valuation:. $3,200.00 SCOPE OF WORK: TEAR OFF-EXISTING�ROOF;�COVER WITH 30 YEAR COMP SHINGLE PER CODE. ROOF PITCH IS 3:12. OWNER: ULLOA, LUCIO�SOCIS Address: 650 DARRELL ST„�.. Unit: PHONE: ... City/State2ip: COSTA MESA,.CA� -, � , APPLICANT: ULLOA, LUCIO SOLIS:. � � , Address:. , 650 DARRELL�.ST � Unit: : PHONE: 949-233-2579 �''�City/State/Zip: COSTA MESA, CA CONTRACTOR: OWNER-BUILDER ��License,No. , .000000°��'";��'� Address: Unit: � �" ; .. � ".. � ' � � ',�` ... .. ., . ... PHONE: .. '� �� ''�.�. . � " City/State/Zip: .:, i ;; . . � , _.. . . .; , ._ . .. - . �- ' CELL; ,, , ,,, ,, , ,;, ,;, [:: a. . . . ' � . . " . . � .. : . . . ARCHITECT: � � � - � � License No. PHONE: ENGINEER: � - � . � License No. � ' PHONE: FEE SUMMARY Reroof Plan Check: Reroof Permit Fee: Reinspection Fee: Bldg Std Admin Fund TOTALFEES n� �: $o.00 ' - � $97.25 -'�� - $0.00 -:; $1.00, � . _ $98.ZS =, ` . .ini;: UniL' . ,..T r�.lsvz�i� 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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE1. INSPECPONTYPE DATE INTITIALS COOEN MSPECTIONTYPE ORTE INTITIAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final / O Q_ 208 Final Plumbing � 'j`"*' 200 Final Re-Roof I � 7 �_. 210 Final Electrical 20T Final BIocWRetaining Wall �� 212 Final Fire Prevention ='-7�`• 202 Final Faclory Fire Place 220 Final Planning Approval 203 Final Sign � 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affrm under penalry of perjury one of the following declarations: ❑ I have and will maintain a, ce�rtificale o( consent to sel4lnsure (or workers' compensation, as providetl for by section 3700 of the Labor Code, for the peAormance of the vrork for which Ihis permit is issued. ❑ I have antl will maintain v.vrkers' compensation insurance, as requiretl by sectbn 3700 of the Labor Code, for the pedormance of Ihe vrork (or which ihis permit is issued. My vrorkers' compensation Insurance carrier and policy number are: Carrier (inu section neeE iat oe mmpele0 d Ihe peima s value0 a1 one nundre0 ddlars (3100) w IessJ �P�li� %Number: Q certify ihat in the peAormance of the vrork tor which this permit is iSsueC, I shall not employ any person in any manner so as to become subject fo the vrorkers' compensation laws of Califomia, and agree Ihat it I should become subject ro ihe workers' compensation provisions of Section 3700 of the Labor Code, I Shall (orthwith�ply wilh lhese provisio 5. �UG�2� (�6 O �fi�SignaWre WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrm that I am licensetl under provisions of Chapter 9(wmmencing with Section 7000) of Division 3 of the Business and Professions Code, antl my license is in tull force and eHect. Lic. # Class # Contrac�or's SignaWre Date CONSTRUCTION LENDING AGENCY: ❑ I hereby aKrm that there is a construction lending agency for the perfortnance o( the v.ork fa which ihis permit is issued. (Sec. 3097, Civil Code�. Lender's Name: Lender's Address: OWNER-BUILDER DECLARATIONS: 1 hereby affirm Ihal untler penalry of perjury [hal I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sea 7031.5, Business antl Professions Code: Any city or county which requires a permit to construct, alter, improve, tlemolish, or repair any stmcWre, prior to its issuance, also requires Ihe applicant (or such permit to fle a signed slalement that he or she is licensed pursuant to the provisions of lhe Contractors License Law (Chapter 9(commencing with Section 7000) of Division 3 of �he Business and Pro(essions Code) or thai he or she is exempt there(rom antl the basis (or the alleged exemption. Any violation of Seclion 7031.5 by any applicant tor a permit subjects the applicant ro a civil penalry of not more Ihan fve undred dollars ($500).): as ovmer of Ihe property, or my employees with wages as their sole , o p�nsalion, WILL DO THE WORK, antl the s[rucwre is not intended or oRered for sale (Sec. 7044, Business antl Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such vrork himself or hersel( or through his or her own employees, provitled 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 vrill have the burden of pmving that he or she did not build or improve for purpose of sale.). ❑ I, as ovmer of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to ConSINCt Ihe projeCl (SeC. 7044, BUSIne55 and Pro/essions Code: The contractars License Law dces not appty to an owner of property vfio builds or improves thereon, and who contracts tor such project with a contracta(s) license pursuant to Ihe Cont2ctors License Laws.). ❑ I am exempt under sec. Business and Pro(essions Code for this reason: ��c,i.� �L� 2 —�- 305]-a6(3I01) , . Owner ID verifed by driver o ncense. ❑ Yes ❑ No Diiver's License No. Expires: Verifcation of Ownership by (rype of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify tha[ no excavation frve (5) or more fee[ in depth into which a person is requiretl Io descend, will be matle in connection with work authorized by this pertnit, antl that no building swcture, scaFtdding, falsev.ork, or tlemolition or dismantling thereof, will be more �han thirty-six (36) feet high. (Chap. 32, Grp 2, Arl 2, Sec. 341, Ttle 8. Calitomia Atlministrative Code). ❑ As owner-builder, I will not employ anyone to do work which woultl 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. Applitanl's SignaWre Da�e Division of Industrial Safety Permit Number HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant neetl to fle antl certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 0( the Calitomia Health and Sa(ety Code requires, wiih some exceptions, that a Business Plan be fled vrith the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantiry of hazartlous 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 standard temperawre and pressure). 2. Does or will Ihe applicanl or present or future building occupant neetl to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Cali(omia Health and Safety Code, wi[h some ezceptions, requires registration with the Costa Mesa Fire Departmen[ 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 standartl tempereture and pressure). 3. Does or will the applicant or preseni or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Seclion 25534 of the Califomia Health and Safery Code provitles that the Costa Mesa Fire Department may require the preparation, certi5cation and flinq with lhe Fire Department of an RMPP by businesses which are required to register aately hazardous materials with the Fire Oepartment. 4. If an RMPP is presently require4 has Section 25534 of the California Health and Safery Code been fully complietl with? ❑ Yes ❑ No 5. Does or will the applicant or present or fuWre buil0ing occupant require for ihe work which is the subjecl o( this appliwtion a permit for such consiruction or modifcation from the South Coast Air Quality Management District or from any other air polWtion control tlistnc� or agency? ❑ Yes ❑ No (Section 65850.2 of Ihe Califomia Govemmen[ Cotle requires Ihat the reques[ed infortnation be fumished on applications for non-residential building permits). 6. Will any part o( the faciliry to be consWcted under this permit be within 1000 (eet from the ouler boundaries of a school? ❑ Yes ❑ No Q!'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health antl Safery Code). 7. If a permit from the South Coasl Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safely Code Section 42303 been made? ❑ Yes ❑ No 8. (If'yes", attach certifcate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify thal untler penalty of perjury the information given above is covecc I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signawre CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I ceAify untler penalty of perjury that I have read this application and state that the information given is correcL I agree to comply with all state laws antl ciry ordinances relating to building consWction, and authorize represeniatives of the City o( Costa Mesa ro enter upon the above-tlescribed properry for inspection purposes. I agree nol to occupy or allow occupa cy of ny building auth rizetl by tOhis pgrmOlt,uqtis5nal inspectioa I I ,1 � L U �Sig'¢lu�e olLeea(;O—wneT7�� AnClor Aul�onze0 Ap01it'anl Da�e CITY OF COSTA MESA BUILDING DIVISION ROOF COVERING CERTIFICATION- PropertyAddress e ..J� ,s-.2.� � � Owner �li-O�O �� f i i Contractor State Contractor License Number PermitNo. ��/� � ��(J�� Classification I hereby certify that I have installed, or caused to be installed, a minimum Class B roof covering at the above address in conformance with Chapter 15, of the latest adopted edition of the California Building Code, and the installation instructions of the manufacturer. �]. I further certi(y that I am the owner oF the property. (Owner-8uilder permittee only). ❑ I further certify that I am: ❑ Owner of sole proprietorship company ❑ Full partner of the company ❑ Limited partner of the company ❑ Officer of the corporation I certify that as an authorized officer or agent of the company or corporation, I am empowered to make this certification, which shall be binding on all successors or assigns of the company or corporation. I shall deliver a copy of this Certification to the above listed owner, after submittal of form to the Building Division for acceptance. Received by Building Division By: Initial 1i ate D � 0990-a6MW6lOB WNIe-BuiltlingDiv.;Canary-GonVactor,Pink-Owner ��r (�Sb ,�..,�I1 5�-- Address Printed or Typed Name `�'-� Cit o Costa �l�lesa �uiCdin �ivision -_�� y .f � Costa M[esa �� Fair Drive, Costa Mesa, CA 92626 714-754-5273/Fax 714-754-4856 OWNER BUILDER VERIFICATION Permit # - VU�_ �LJ Disclosures & Forms for Owner- Builders Applying for Construction Permits IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been submitted in yo r na e I �i�`1(ourself a h buil the property improvements specified at �) k,�,�,�� $� �, S� � LJ../�/QYI�� •. We are providing you with an Owner-�ultder Acknow edl" gment and Information Verification Form to make you • aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. Read and initial each statement below to signify you understand or verify this information. �,(��I' I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. � ��2';I understand building permits are not required'to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. C%3' I understand as an "Owner-Builder' I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. C�4. I understand Contractors are required by law to be licensed and bonded in Califomia and to list their license numbers on permits and contracts. �,�5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500}, including labor and materials, I may be considered an "employer" under state and federal law. �� ✓br'I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. ��.! I understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 3148-3D CALBO Jan 1, 2009 OB Packet template 1 of 2 �/—!-Sil understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or'personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. ��9 I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. C�=S�. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: l/L, ✓ 11'. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. C��. I agree to notify the issuer of this form immediately of any additioris, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any fnancial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and retumed to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's /icense. form notarization, or other verification acceptable to�cy �s required to be presented when the permit is issu d to verify the propeRy owner's signature. 6ig�n ttire.of-pr peo'�'rty owner �Pi+l� �'�if' rDate: �� C�l.� l.l in Il��i-��o � Note: The following Authorization Form is required to be completed by the property owne� only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder. AUTHOFt12ATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: .�f ame:o�Authorizetl'AgenG Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signatur . ,. P , P[operty�Owners;Signature:.� �LC.o�7 �� r' Date: %� O?�Oi 3148-30 CALBO Jan 1, 2009 OB Packet template 2 Of 2 . caasi M�S'!4 Addressof / �� j�^,^!� ( / � CITY OF Buildin9 --- --�� kf !Q � �j�`k4--`------- _... __.___...._ Off-Site DEPARTMENT OF Fabriwtor.--'------'---'----------'--'----------------.....----------- BUILDING AND SAFETY }� �c,�, / BUILDING INSPECTION Permit j2� l._[/ �� ✓-__/J�far """_"""_'______ UATE OVf 5//F� �/� Number __.'___L7 �.� l// TO THE SUPERINTENDENT OF BUILDING: CITY INSPECTOR: I hereby certify that the following portions of the work at the above address which required continuous inspection, and which I was employed to inspect, were inspected by me and comply with the provisions of the Building Code applicable thereto: Type of inspection: ❑ Mawnry ❑ ReBar Placement ❑ Concrete or Mixer ❑ .Welding ❑ Concrete Placement ❑ Gunite ��,, rn/��(� ❑ Hi-Ten Boits ❑ Tendon Placement �( Other ____.�./.._.'�._��;'/ _---... V Description and location of work completed: _________________________y /_'�{_________________..-.-y)_/_,_„�-�---__ -� H� Ir n, i r_ 1.- r?-f .A,� �.e n G i. t! .i ,f7 � 9/7 %�// � / fi'GF.i<ili h — �i'/L v2 $ize of Structure .. Time Arrived „�. No. of Stories --""",--"'--'--`--.'!'_-'-----,_. -"'--"--`-------"-'--- �Time Leh 1ob . ,..� u: ��~�Con[. Mix Desipn No. _.."'__._..__"'_...____"'___ Psi _...._._."'_.__ Swimming Pool 1 had sufficimt time to inspecf all materials used and placed. I was rat empl ed by the contractor, wbcontnctor or m; -- ---------------�-- -�r?:� z.`.�.�3 �- ------- ----- - Re9�stration N Employed By: Lab. ----......-----'-`-----_"_--'-"-__'---"--'------"------- Independent ❑ B 8 g B-9� (F. 10/B81 � aec,:au! a�s � .r,^..-:�Fa� rsvv �d� OWNER AP. No. W. Darrell Street �it Dike 8: Colegrove FII2E ZONE LOT 21 1RACT 2; I & J TYpE V INSPECTIONS coa! Test DATE SUBCONTRACTOR BUILDING PERMIT NO. VAL[IE $ Res. Att. Gar, DATE � NUMBER . � . � � . . � �-i � � � �`�� COSTA MESA BUILDING DEPARTMENT P. O. BOX 31] COSTA MESA, CALIFORNIA . FORAPPLICANT TO FILL IN I BUILOING COSTA MESA, CALIFORNIA OWNER �7$(�Gd xntt nancno ADDftE55�9 E• 1/th St• IARCHITECT OR ENGINEER LECAL LOT DESCRIPTION NO. A.P. NO. S�ZE 61 x OF LOT USE OF EXISTING 6LDG. $ET9PCK LINE FROM NO. LIC. NO. CITV LIG d�'ry NO. �Vf� �- TEL. �. w - e�'�� R�CEiVE� �-30 -s� �IV�A�ICE OEPT. �fTY OF CQSiA lI�SA APPLICATION FOR PERMIT BUILDING FOR OFFICE USE ONLY RECEIPT NO. � NO.OF 9L0G5. NOW ON LOT none SIDE YARO RIGHT � LEFT V� DESCRIPTION OF WORK NEW � ALTERATION I AOpIT10N REPAIR MOVING DEMOLISH SIZIE�ING �30 $^ � ROOMS 6 STORIES Y EXTERIOR WAL1� ROOF COVERING . �7tuCCO COVERING CO • USE OF NEW _ . _ _ B111L�ING ADDRE55 COSTA MESA. CALIFORNIA wlth attached garage. Plan 13oB I HEREBV ACKNOWLEDGE THAT I HAVE RETO iH15 APPLICf�TION RNO STl�TE TMAT iHE ABOVE IS CORRECT wN0 AGREE TO COMPLY WITH 4LL CITT�ON�INANCE$ AND ST/TE LtWS PEGULFTING BUIIDING CONSTPUC- TIOrv. �� /� VALUATION SIGNATUREOF ��f�� IAUTHORIZEO AGENT �ne � DATE CORRECTIONS s 1.4, 526.00 PERMIT FEE S 3�y�OO PLAN CHECK $ y��OO TOTAL FEE 8 S� _M �oMr i JOB ADDRESS � GENERAL CONTRACTOR owner builder VALUE $ 31�1•00 AP. No. LOT TRACT FIRE ZONE DESCRIPTION OF WORK'�block Wfll.]. WSPECTIONS � oATE I GROUP TYPE ZONE SUBGONTRAGTOR Form 410-3M-4-59 � f_ _ :��: � COS A MESA BUILDING-SAFETY DEPARTMENT P.O. BOX 31] COSTA MESA. CALIFORNIA FOR APPUCANT TO f/LL /N COMPLETE[Y TYPE OR PRINT - COSTA MESA, CALIFORNIA MAII 1l V(� r r Gl/ �� ADDRE55 G TEI. QTY G Gr � NO. ARCHITECT LIC. OR ENGINEER NO. A�LEGAL SIZE / / �/ �� I NO.OF BLOGB. OF LOT �/ /� NOW ON LOT USE OF EXISTING BLOG. i G.�1 i d� YL G'P � SETBACK LINE FROM I}� I� cexreA oF srReer ..7 6 7 REAR YARD O �f� �� SIDE YARD LEFT �.! IRIGHT DESCRIPTION OF WORK BU ZONE �=CE RECE(VED JUL 2 7 1959 FituqNr.F pFPT APPLICATION FOB PERMIT �.IiY �F C(1SfA Mt$A BUILDING fOR Off/CE USE ONCY IRECEIPT NO. I 7�1 zfyED+ /gY DATE RECEI�VE�Dq DATE ISSU J d� I � � '� 7 J / I � � � � NS l• .� �� [iLil-G`/� —� COSTA MESA, CALIFORNIA ZONING NO.OF I USE OF NEW PLANS �� BOILDINp YARDS REOUIRED (LENTER LINE ST.J FRONT BUILDING NO.OF SIZE ROOMS STORIES EXTERIOR WALL � �IROOF COVERING COVERING $f USE OF BUILDING ANO WORK TO BE PE O ED ,/�� " l�ne�f �f/a-P. 6 / � � c-F G • � O • �% �� X �✓�,iG/�C.a)»>�. ii i y✓i � �. HEflEBY ACNNOWLEDGE THAT 1 HAVE READ THIS NPPLICATION THE AMOUNT SXOWN UNOEN VALUATION I6 FOR THE ANO STATE TNAT THE PBOVE IS COflFECT ANO AGFEE TO COM- pUqPOSE OF ESTABLISHING A PERMIT FEE ONLY. .PLY WITH ALL CITY ONUINANCES ANO STATE LAWS FEGULATING am�oiNc coNSreucrloH. VALUATION �} P RMnITTEE OF � `� � J.p PERMIT FEE $ p[_ U� ' J �T� PLAN CHECK $ AUTHORIZE� AGENT $ �� L ;' ' '? TOTAL FEE $ �