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HomeMy WebLinkAbout1142 SOUTH COAST DR - Building PermitsJu •-' O� F• CITY OF COSTA MESA a a 9 N, BUILDING DIVISION F I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT w,, ' B05-00184 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 1142 SOUTH COAST DR Status: ISSUED . Suite: 1114 Applied: 01/31/2005 Vicinity: BLDG 114 Issued: 01/31/2005 - Parcel Number: 41208411 Zoning: , Applicant: RON OSSENBERG ISSUED BY: //- Address: 8111 COMMONWEALTH Phone: 800-400-7692 BUENA PARK,CA Zip: 90621 Owner: WIMBLEDON GLEN ASSOC L P Address %ARNEL MANAGEMENT CO `• - ane COSTA MESA,CA Phone: - ® '�1 950 S COAST DR STE 200 Zip: 92626 • .' 7. Contractor: ROYAL ROOFING CO Address: 8111 COMMONWEALTH Phone: 800-400-7692 , BUENA PARK,CA Zip: 90621 Licenser 678705 . Arch Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT TEAR OFF EXISTING ROOF.INSTALL ROCK BASE,2 PLY AND#5 GRAVEL. BLDG. 1114 • FEE SUMMARY Plan Check: $0.00 Calc Valuation: $5,100.00 Permit: $125.25 . Claim Valuation: $5,100.00 SMIP Res: $0.51 , SMIP Com: $0.00 - Other: $0.00 - ' i Inspection: $0.00 " Total: $125.76 , - PLANNING &ZONING SETBACKS - MAIN STRUCTURE Front 0-0 -. Rear -0-0 Left 0-0 Right 0,-0 ACCESSORY Front 0-0 . Rear 0-0 Left 0-0 , Right . 0-0 " PARKING Existing: 0' Required: 0 Proposed: -0 - NOTES: - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446.46(6/00) r+ ' DECLARATIONS "r �' a WORKERS'COMPENSATION DECLARATION: / I hereby affirm under penalty of perjury one of the following declarations: • ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. My workers'compensation Insurance carrier and policy number are: Carder: Policy Number: _ (This section need not be completed! 'permit is valued at one hundred dollars($100)or less.) $ .44certi fy that in the perfo of the work for w h this permit is issued,I shall not employ any person In any manner so as to•:come - bject to the workers' +_....----compensation laws of //////� and/agree that• I should become subject to the workers'compensation provisions of Section 00 of T e Labor Code,I shall forthwith comply with these pr. 1/ ! 1(25— Applicant � AAp�pplic--a--n--^tt Signature: AIL d . . . _A A_ JJ''Date: l YMRNMID.'FAILTIRE TO S. U•. ERS'COMPENSATION COVERAG A IS UNLAWFUL MID SWILL SUBJECT AN EMPLOYER TO CRIMI "ENALTIES • D CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000).IN ADDITION TO THE COST OF COMPENS•TION,DAMAGES AS PROVIDED FOR IN SECTION 37050F THE •.:•R CODE.INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensegu pr•vlsi•• of- Chapter 9 ommencing with Section 7000)of Division 3 of the Business qny Plgfe -'•ns Code,and my license Is in full force.and effect:Cic:pw r r^Class.$. ( ° c� �Co atractor :' %/rIa -. -- 4Oare Ai _ WAIr -t 1� y. i . �— I �--- " CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agenc for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lender's Address: Signature: Date: rt�l_ OWNER-BUILDER'DECLARATIONS:, �-, I hereby affirm that under penalty ofperjury that l'am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a.perimit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 1 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the Calitomla Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). • 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 8 No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Co-a Mesa to enter upon the above-described property for' spection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until 'nal ins =ction. r A A,©gnature of Legal Owner(s) Date CODE 0 • :/ L' On INTMALS CODE( INSPECTION TYPE ---PAIL IBIIDALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1286 Pool Spa Final /}� 208 Final Plumbing 200 Final Re-Roof I O - 210 Final Electrical 201 Final Block/Retaining Wall .1' .4!ar1• d 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 soli '6 CITVbF COSTA MESA 4 ,►° BUILDING DIVISION )y ,,,,, ai • DEVELOPMENT SERVICES DEPARTMENT PERMI NUMBER v. tfi /ti t PERMIT v !" r- 01.4" B05-00185 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 1142 SOUTH COAST DR Status: ISSUED Suite: 1117 Applied: 01/31/2005 Vicinity: BLDG 1117 Issued: 01/31/2005 I Parcel Number: 41208411 Zoning: Applicant: RON OSSENBERG ISSUED B Address: 8111 COMMONWEALTH , Phone: 800-400-7692 BUENA PARK,CA Zip: 90621 Owner: WIMBLEDON GLEN ASSOC L P Address %ARNEL MANAGEMENT CO COSTA MESA,CA Phone: V1, 1 I 950 S COAST DR STE 200 Zip: 92626 _ • "At A awi-""r.�/ Contractor: ROYAL ROOFING CO /VAlit r Address: 8111 COMMONWEALTH Phone: 800-400-7692 BUENA PARK,CA Zip: 90621 License: 678705 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT . TEAR OFF EXISTING ROOF.INSTALL ROCK BASE,2 PLY AND#5 GRAVEL. BLDG. . FEE SUMMARY Plan Check: $0.00 Calc Valuation: $5,100.00 Permit: $125.25 - Claim Valuation: $5,100.00 SMIP Res: $0.51 SMIP Corn: $0.00 • • Other: $0.00 • Inspection: $0.00 Total: $125.76 PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right. 0-0 , ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No. 92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections end final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 244646(6/ ) • DECLARATIONS WORKERS'COMPENSATION DECLARATION: :. I hereby affirm under penalty of perjury one of the following declarations: ❑ I have end will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall fdrthwlth comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE(4100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.It Class$ Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of properly who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: In I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made In connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title B,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division, Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas al standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date And/Or Authorized Applicant Date CODE, INSPECTION TYPE QdB JNTITIALS gODEt INSPECTION TYPE PATE INRTIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign _ 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 1, CITY OF COSTA MESA• BUILDING DIVISION ,.:j ____ , DEVELOPMENT SERVICES DEPARTMENT PE T NUMBER h r ,...�.�. .� PERMIT 44 ;so B05-00089 (714)754-5273 • Fax(714)754-4856 • www.cl.costa•mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 1142 SOUTH COAST DR Status: ISSUED Suite: Applied: 01/18/2005 Vicinity: APT BLDG 1102(WIMBLEDON GLEN) Issued: 01/18/2005 Parcel Number: 41208411 Zoning: / Applicant: POWDERLY, PAUL ISSUED BY: t ia Address: 8111 COMMONWEALTH - _ Phone:-800400-7692 BUENA PARK,CA- ./ Zip: 90621 - Owner: WIMBLEDON GLEN ASSOC L P Address %ARNEL MANAGEMENT CO - ' .4 Lot COSTA MESA,CA - Phone: - _ - �_� • —IIII - 950 S,COAST DR SIE 200. -- Zip: 92626 Min s/► Contractor:' ROYAL ROOFING'CO ®' Address: `8111 COMMONWEALTH ' Phone: 800-400-7692 BUENA PARK,CA - Zip: _ 90621 : License:" 678705 . Arch - - ` Eng: Address: Address: . Phone: . .. , Phone: - Zip: License: . License: SCOPE OF PERMIT REROOF APT BLDG 1102:T/O EXISTING B.U.R.AND INSTALL NEW B.U.R.(BASE-THREE 11#ROCK). _ -7 ,. - i , - , - FEE SUMMARY - Plan Check: $0.00 Calc Valuation: $6,850.00 • - ' Permit: -$139.25 • . - ,, Claim Valuation: $6,850.00 SMIP Res: ' $0.69 ' SMIP Corp: ' $0.00 • ' _ - ' - /,./ ,y - - Other , . $0.00 �i • . Inspection:. $0.00 . ; AvTotal: $139.94 „ ' .r'✓- v`� v . ' " PLANNING & ZONING.':.-:'- -" % , , / SETBACKS, /% • '/. , MAIN STRUCTURE Front 0=0 N_ .Rear ' 0-0- i 7 ACCESSORY N/ Front ' 0-0 Rear; -0-0 • - - -Left -0-0 Right 0-,0"/ PARKING Existing -. 0"--,: ;/Required:` , 0 Proposed: :0 . • NOTES: ''- NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days,or If work Is suspended or abandoned for a period of 180 days. ,' , , INSPECTIONS: In order for the work authorized under this permit to be considered legal; such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2448-48(6(00) . DECLARATIONS `' WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ' ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. -• ❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit Is valued at one hundred dollars($100)or less.) • EfP. I certify at in the pert mance of th 'ork for• hich this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compen tion laws o alifomia,and =gree tha f I should bac•subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply wit thes ovisions. Applican na re: •_ =Data: 1 j WARM G:FAILURE TO SECURE WORKERS ..4 PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRI INAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOC ARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I arryliOVpygU u r tyt. Ions of Chapter 9(commencing with Section 7000)of Division 3 of the Busipeg5 aebl�rrsfessions Code,and my license Is In full force and effe�It(() {, C��+ Foss a L--- `�-1 Contractgignatura-tel n Q es. ( —( 2( /. _ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: O W NER•BUILDER,DECLARATIONS: 1r11V'" - I hereby affirm that under,penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or cotinty,which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that'he-or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or thathe'or-shie is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made In connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need.to file and certify a Business Plan for emergency response to release or threatened release of a hazardous matelot? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to tile a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of 1 compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? Dyes No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. • �cr1 ) ?Applicant D -- CODEIt INSPECTION TYPE • PAIL MALI 9o0Ef INSPECTION TYPE GAIL IIDIDAL9 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof rate 210 Final Electrical 201 Final Block/Retaining Wall - 212 Final Fire Prevention 202 Final Factory Fire Place ' 220 Final PlanningApproval 203 Final Sign 222 Final Site 204 Final Demolition - • 250 Final Building/Occupancy-