HomeMy WebLinkAbout1995 ANAHEIM AVE - Building Permits • dll
CITY OF COSTA MESA
BUILDING DIVISION
>Y, .A, 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
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. 1.1511 . FOR INSPECTIONS CALL: (714)754-5626
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PERMIT NUMBER: BC10-00315
PERMIT TYPE: B_COMBO STATUS: ISSUED
Sub Type: RES_ALT DATE ISSUED: 08/25/2010
ISSUED BY: CAC
JOB ADDRESS: 99'�,YS AN�AHEIM AV CM Suite/Unit:
APN: 42214203 Zoning: , ,
Vicinity: Primary Occ:
Const Type: V-B SQ. FT: 642 Valuation: $61,269.60
SCOPE OF WORK: FIRST FLOOR ADDITION.APPROX 602 SQ FT AT REAR UNIT. SCOPE OF WORK CONSISTS OF NEW
LIVING ROOM,NEW MASTER BEDROOM, BATH AND WALK IN CLOSET.CONVERT EXISTING LIVING ROOM INTO DINING
ROOM. NO KITCHEN REMODEL.40 SQ FT PORCH TO BE ADDED TO FRONT OF THE UNIT. ELECTRICAL TO INCLUDE: 16
LIGHT FIXTURES,
10 OUTLETS AND 7 SWITCHES. PLUMBING TO INCLUDE: 1 BATH TUB, 1 SHOWER, 1 WASH BASIN AND 1 TOILET.
OWNER: ARROYO,BENJAMIN Address: 1995 ANAHEIM Unit:
Phone: 949-244-8034 City/State/Zip: COSTA MESA,CA
APPLICANT: MACIEL,RICARDO Address: Unit: :
Phone: 310-308-6719 City/State/zZip:
CONTRACTOR: License No.
Phone: Address: Unit:
Cell: City/State: ZipCode
ARCHITECT: License No. PHONE:
ENGINEER: MIDCITIES ENGINEERING License No.41697 PHONE:562-866-3625
COMBINATION PERMIT FEE SUMMARY
Building Plan Check: $473.04
Building Fees: $727.75
Electrical Fees: $59.80
Mechanical Fees: $0.00
Plumbing Fees: $62.70
SMIP Residential: $6.13
SMIP Commercial: $0.00
Bldg Std Admin Fund $3.00
TOTAL FEES: $1,332.42
'Refer to fee receipts for all fees paid for project
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010- PER CMMC Soc. 13-279
Monday thru Friday•7:00 am thru 7:00 pm. Saturdays-9:00 am Ihru 6:00 pm. Prohibited all hours-Sundays and the following Federal holidays:
New Years Day,Memorial Day,Independence Day,Labor Day,Thanksgiving Day and Christmas Day
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE I. INSPECTION TYPE WI E INITAL$ CODE! INSPECTION TYPE DATE INTTIIAL$
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 v V 1p— I�Ii m P [A✓
S ` a
WORKERS'.COMPEN€ATION DECLARATION: Owner Q- erified b driver's license.Ges 0 No 7
I hereby affirm under penalty of perjury one of the following declarations: river's Licenae'No. F�xpires: �3'((- (7
❑ I have and will maintain a certificate of consent to self-Insure for workers' enfication of Ownership by(type of document.i.e.-property tax bill or deed):
compensation, as provided for by section 3700 of the Labor Code, for the _,
performance of the work for which this permit is issued.
O 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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet hi depth into which a
number are: person is required to descend,will be made in connection with work authorized
by this permit,and that no building structure.scaffolding.falsework.a demolition
Carrier: or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp
(This seam need not be competed thepemtl b valued al one hovered dWars(Sicc/ar fess.)
2,An 2.Sec.341,Title B,Califomia Administrative Code).
Policy Number:
0 As owner-builder, I will not employ anyone to do work which would
O I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California. and agree that if I should
become subject to the workers'compensation provisions of Section 3700 of Applicant's Signature Date
the Labor Code.I shall forthwith comply with these provisions.
Division of Industrial Safety Permit Number:
Applicant's Signature D`i18 HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100,000), IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? ❑Yes 0 No
Lic.# Class# (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
Contractor's Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
O I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? 0 Yes 0 No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: 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.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes ❑No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑Yes ❑ No
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 (Section 65850.2 of the California Government Code requires that the requested
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the information be furnished on applications for non-residential building permits).
Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feel from the outer boundaries of a school? ❑Yes ❑No
applicant for a permit subjects the applicant to a civil penalty of not more than (If yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
Cl
I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
co pensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec. 7044, Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by Califomia
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? ❑Yes ❑No
thereon,and who does such work himself or herself or through his or her own
8. (If"yes",attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions.
property,
❑ I, as owner of the
LICENSED CONTRACTORS to construct the project(Sec.7044.Business and
Professions Code:The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contracta(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
❑ am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: 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
/y authorized by this permit until final inspection.
1S Z—s — D signawr of Legal()pawls) Date/ Date
142' Signature _ "'.74,e O'25—(a
3057-4513/07)
at
I. V i 1V III 11
CITY OF COSTA MESA
`L05Tp"'Fsp BUILDING DIVISION
F 4 _,,,,• a ' 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
FOR INSPECTIONS CALL: (714)754-5626
° "' PERMIT NUMBER: BC11-00509
PERMIT TYPE: B_COMBO STATUS: ISSUED
Sub Type: RES ALT DATE ISSUED: 09/27/2011
ISSUED BY: RMD
JOB ADDRESS: 1995 ANAHEIM AV CM Suite/Unit:
APN: 42214203 Zoning: , ,
Vicinity: GARAGE AREA Primary Occ:
Const Type: V-B SQ. FT: 0 Valuation: $500.00
SCOPE OF WORK: REPLACE STUCCO AT GARAGE, REPLACE 1 WINDOW LIKE FOR LIKE (SAME SIZE, SAME HEADER)AND
RELOCATE GAS, 1 OUTLET AND WATER LINES FOR LAUNDRY WASHER/DRYER. ELECTRICAL TO BE WEATHER
PROTECTED.
OWNER: ARROYO BENJAMIN AND BLANCA E Address: 871 SENATE ST Unit:
Phone: 949-244-8034 City/State/Zip: COSTA MESA, CA
APPLICANT: ARROYO, JAIRO Address: Unit: :
Phone: 949-244-6034 City/State/zZip:
CONTRACTOR: OWNER-BUILDER License No. 000000
Phone: Address: Unit:
Cell: City/State: ZipCode
ARCHITECT: License No. PHONE:
ENGINEER: License No. PHONE: •
COMBINATION PERMIT FEE SUMMARY
Building Plan Check: $0.00
Building Fees: $23.50
Electrical Fees: $24.60
Mechanical Fees: $0.00
Plumbing Fees: $39.45
SMIP Residential: $0.50
SMIP Commercial: $0.00
Bldg Std Admin Fund $1.00
TOTAL FEES: $89.05
•
"Refer to fee receipts for all fees paid for project
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279
Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibited all hours-Sundays and the following Federal holidays:
New Years Day,Memorial Day,Independence Day,Labor Day,Thanksgiving Day and Christmas Day
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.
COC�EI INSPECTION TYPE DAT INITALS CODEC INSPECTION TYPE DATE IN1111ALS
1816 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof , -N\YM",,. 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
WORKERS'COMPENSATION DECLARATION: Owner ID verified by driverse. ❑Yes ❑No
I hereby affirm under penalty of perjury one of the following declarations:. Driver's License No. Expires:
❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document.i.e.-property tax bill or deed):
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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
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 ❑ I hereby certify that no excavation five(5)or more feet in depth into which a
number are: 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
Cartier: or dismantling thereof,will be more than thirty-sic(36)feet high.(Chap.3.2.Gm
(This seam need#01 be cwnWeted'the pennrl is valued at one hundred dofars(MO a less) 2.Ant Sec.341.Ttle 8.California Administrative Code).
Policy Number:
❑ As owner-builder, I will not employ anyone to do work which would
9 .1 certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
issued,I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California. and agree that if I should
become subject to the workers'compensation provisions of Section 3700 of AppliUnl's Signature Date
the Labor .de.I shall forth ' • comply with these provisions.
9•/27/���� Division of Industrial Safety Permit Number:
0/a
App cant's Sg _. to HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes 0 No
(5100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST.AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? 0 Yes 0 No
Lic.# Class# (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
Contractor's Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affum that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? ❑Yes 0 No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: 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.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be fumished on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes",the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars(5500).): of the California Health and Safety Code).
VI I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
ompensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec. 7044,Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? ❑Yes 0 No
thereon,and who does such work himself or herself or through his or her own
8. (If yes attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
O I. as owner of the property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions.
LICENSED CONTRACTORS to construct the project(Sec.7044,Business and
Professions Code:The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
0 I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: 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.
- -_-- 9172 7/i/ Signature of legal Owner(s) yDate
lC�
ure ,-.OCIn
atte_ /f /
576 43/07) AnNar Authorized Apr.. nt Date
CITY'OF COSTA MESA
GoFs'g0 BUILDING DIVISION
°4M112-LAI R 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.costamesaca.00v
4. I FOR INSPECTIONS CALL:(714)754-5626
PERMIT NUMBER: B11-00366
PERMIT TYPE B_ROOF2 STATUS: ISSUED
APN: 42214203 DATE ISSUED: 10/21/2011
ISSUED BY: RMD
JOB ADDRESS: 1995 ANAHEIM AV CM Suite/Unit:
Vicinity: GARAGE
Squares: 0 Valuation: $2,000.00
SCOPE OF WORK: TEAR OFF EXISTING ROOF MATERIALS, INSTALL A MINIMUM OF 2 LAYERS OF 15#FELT ON A 2:12 TO LESS
THAN 4:12 PITCHED ROOF OR A MINIMUM OF 1 LAYER OF 15#FELT ON A 4:12 OR GREATER PITCHED ROOF:
REROOF WITH COMP SHINGLES ON A DETACHED GARAGE ONLY.
NOTE:RESIDENTIAL RE-ROOF: Final approval of permit shall not be granted until access to dwelling unit(s) is provided for
verification of the installation of smoke and carbon monoxide alarms by the City Inspector. See Attachment w/Inspection Card
OWNER: ARROYO BENJAMIN AND BLANCA E Address: 871 SENATE ST Unit:
PHONE: 949-244-8034 City/State/Zip: COSTA MESA,CA
APPLICANT: ARROYO,JAIRO Address: Unit: :
PHONE: 949-244-8034 City/State/Zip:
CONTRACTOR: OWNER-BUILDER License No. 000000
Address: Unit: • PHONE:
City/State/Zip: CELL:
ARCHITECT: License No. PHONE:
ENGINEER: License No. PHONE:
•
FEE SUMMARY •
•
Reroof Plan Check: $0.00
Reroof Permit Fee: $69.25
Reinspection Fee: $0.00
Bldg Std Admin Fund $1.00
TOTAL FEES $70.25
HOURS FOR CONSTRUCTION ACTIVITY; EFFECTIVE 3/18/2010-PER CMMC Sec. 13.279
Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibitied all hours-Sundays and the following Federal holidays
New Years Day,Memorial Day, Independence Day,Labor Day,Thanksgiving Day and Christmas Day
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28.§ 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE A INSPECTION TYPE Q 1 INIUTAL$ coot t INSPECTION TYPE pplg INTI11ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final _ 1 '' 208 Final Plumbing
200 Final Re-Roof X !— 5— I a /'Y 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
WORKERS'COMPENSATION DECLARATION: .Ownersll verified by driver's license. 0 Yes 9 No
I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires:
❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document.i.e.-property tax bill or deed):
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
0 I have and will maintain workers'compensation insurance,as required by DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
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 0 I hereby certify that no excavation five(5)or more feet in depth into which a
number are: person is required to descend,will be made in connection with work authorized
Carrier: 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
(ThissaGon need not be completed the pemMu valued at one hunched dollars(f100)ales s)
2,Art 2,Sec.341,Title 8,California Administrative Code).
Policy Number:
0 As owner-builder, I will not employ anyone to do work which would
Ca713certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
issued,I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should•
become subject to the workers'compensation provisions of Section 3700 of Applicant's Signature Data
the Labor Code,I shall forthwith comply with these provisions.
// �iC�O/�/ /(r Division of Industrial Safety Permit Number:
o'lAphga' natureif---- , HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons. or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000) of Division 3 of the Business and Professions Code, and 2 Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? 0 Yes 0 No
Lic,ft Class X (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
comraads Signature Data 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,CMI Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lenders Name: hazardous materials)? 0 Yes 0 No
(Section 25534 of the California Health and Safety Code provides that the
Lenders Address: 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.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No
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 (Section 65850.2 of the California Government Code requires that the mits),requested
information be furnished on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? 0 Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If'yes',the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars(8500).): of the California Health and Safety Code).
®t I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
Cc Th ensallgn, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
thereon,and who does such work himself or herself or through his or her own 8. (I1' es',attach certificate of compliance from the
employees, provided that such improvements are not intended or offered for yappropriate air pollution
• sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions.
❑ I, as owner of the
LICENSED CONTRACTORS to construct the project(Sec.7044, Business and
Professions Code: The contractors License Law does not apply to an owner of Signature Data
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
❑ I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction,and authorize representatives of
Business and Professions Code for this reason: 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 t is permit unti final inspection.
Mk/
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3057.46(3/07r
Ancor Authorized Applicant Date