HomeMy WebLinkAbout129 BROADWAY - Building Permits CITY OF COSTA MESA
eontisQP BUILDING DIVISION
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77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
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FOR INSPECTIONS CALL: (714)754-5626
PERMIT NUMBER: B11-00158
•
PERMIT TYPE B_ROOF2 STATUS: ISSUED
APN: 42545121 DATE ISSUED: 05/18/2011
ISSUED BY: RMD
JOB ADDRESS: MUBRO'ApWA� YS Suite/Unit: •
Vicinity: FLAT AREA
Squares: 2100 Valuation: $6,000.00
SCOPE OF WORK: PARTIAL REROOF OF FLAT AREA ONLY.TEAR OFF EXISTING ROCK ROOF AND INSTALL 3-PLY BUR ROCK ROOF
ON AN ATTACHED DUPLEX AND CARPORT: FLAT AREA ONLY,APPROX 21 SQUARES. REPAIR AND REPLACE
SHEATHING AS NEEDED. COMPLIANC FORMS ATTACHED TO JOB CARD AND CITY PERMIT.
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: VEYNA,RICHARD W AND TERRY P Address: 15188 CARRETERA DR Unit:
PHONE: City/State/Zip: WHITTIER,CA
APPLICANT: TILL, BRANDON Address: Unit:. :
PHONE: 714-606-0669 City/State/Zip:
CONTRACTOR: TILL ROOFING License No. 833820
Address: 3601 S TIMBER STUnit: PHONE: 714-423-9228
City/State/Zip: SANTA ANA,CA 92707 CELL: 714-606-0669
ARCHITECT: License No. PHONE:
ENGINEER: License No. PHONE:
FEE SUMMARY •
Reroof Plan Check: $0.00
Reroof Permit Fee: $125.25
Reinspection Fee: $0.00
Bldg Std Admin Fund $1.00
TOTAL FEES $126.25
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 Califomia 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.
CODES. INSPECTION TYPE DATE INTmALS CODES INSPECTION TYPE DATE IN1111ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final TS 208 Final Plumbing
200 Final Re-Roof • X (9-Ilo��t r'O4i/ W 210 Final Electrical
201 Final Block/Retaining Wall _ 212 Final Fire Prevention
202 Final Factory Fire Place 220 Anal Planning Approval
203 Final Sign _ 222 Final Site
204 Final Demolition _ 250 Final Building/Occupancy
•
WORKERS'COMPENSATION DECLARATION: Owner ID verified by drivense. ❑Yes 0 No
I hereby affirm under penalty of perjury one of the following declarationsi . ' 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.
Sin 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 ❑ 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
r� �7 -C r /J by this permit,and that no building structure.scaffading,falsework,or demolition
Carrier. 7 fM•.B�'t or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp
(The seaon need not be completed the perm$is valued at one hundred dollars(51W)or less.)
2,Art 2,Sec.341 Title B,California Administrative Code).
Polity tuber: lC1 u
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 - Appi¢amsSlgnawre Date
th- Labor Code,I shall f•. with comply with these provisions.
sff-;
-/( Division of Industrial Safety Permit Number:
Ahdicanl's i•aa L.,Uate. 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 ❑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 isinfull force and effect. a registration form for acutely hazardous materials? ❑Yes ❑ No
Lic.�l�6 �o Class#�--C' 37 (Section 25533 of the California Health and Safety Code, with some
C r
C. /8-// exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
Contractors,gnaiure 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 fa 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 ❑ No
(Section 25534 of the California Health and Safely 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? ❑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? ❑Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the Califomia Govemment Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors 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? ❑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).
❑ 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
compensation, 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 ❑ 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
❑ 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
❑ 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 properly for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
Signature of L+-- t • Date
Sgnamre Date ) 8. /1
3057.46(3/07)
1And/or Authorize• '•p leant,_ L�Date-
CITY OF COSTA MESA
FBF �y BUILDING DIVISION
A% �l 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
F
k FOR INSPECTIONS CALL: (714)754-5626
°'^ °" PERMIT NUMBER: B10-00330
PERMIT TYPE B_ROOF2 STATUS: ISSUED
APN: 42545121 DATE ISSUED: 11/04/2010
ISSUED BY: RMD
•
JOB ADDRESS: 1a29"BROADWAY„CM _ Suite/Unit: •
Vicinity: ROOFaJ
Squares: 100 Valuation: $400.00
SCOPE OF WORK: ROOF REPAIR TO A 3 UNIT TOWN HOUSE, APPROX 100 SF.WORK TO INCLUDE THE REPLACEMENT OF MASTIC,
AT SEAMS ON A GRAVEL FLAT ROOF WHICH ARE CAUSING ROOF TO LEAK.
REF#:C10-1418
•
OWNER: VEYNA, RICHARD W AND TERRY P Address: 15188 CARRETERA DR Unit:
PHONE: 562-360-1313 City/State/Zip: WHITTIER,CA
APPLICANT: VEYNA,RICHARD Address: 15188 CARRETERA DR Unit: :
PHONE: 562-360-1313 City/State/Zip: WHITTIER,CA •
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: $23.50
Reinspection Fee: $0.00
Bldg Std Admin Fund $1.00
TOTAL FEES $24.50
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 S. INSPECTION TYPE DATE INIITIAIA CODEC INSPECTION TYPE DATE INTn1ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final /� 208 Final Plumbing
200 Final Re-Roof 11-11-11..) 5M o0 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 DECLARATI Owner ID verified by r's license. Yes ❑ No
I hereby affirm under penalty of perjury one-of the following declarations:- Dovecs.License No. Ex trash 6
p
❑ 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 ill 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 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
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 section neednot be completed d the perm(rs valued al one hundreddooms($100)or less)
2.Art 2,Sec.341 Title B,California Administrative Code).
Policy Number:
0 As owner-builder, I will not employ anyone to do work which would
6:1-17n?_. tify 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 taws of Califomia, and agree that if I should
become subject to t - .•rkers'compensation provisions of Section 3700 of
the Labor C•r s Iyhwi r ••-ply-with these provisions. Applicant's Signature Dale
Division of Industrial SafelyPermit Number:
/ rv_ 1//j A
FAT).ianfa Signature (Da 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 ❑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 ❑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 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)? ❑Yes IDNo
(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 Dale
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 ❑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? El 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 (Section65850.2fu of the California Government Code requiresbuildingnt thee mite),requested
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the information be furnished on applications for non-residential 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 feet 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
fivefI,hundred dollars($500).): of the California Health and Safety Code).
— 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
I-L7compensation, 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 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 control officer
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 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
❑ 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)onlicense pursuant to the Contractors License Laws.), certify under penalty of perjury that I have read this application and stale that
IEY:-.1 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: 770 yY the City of Costa M-sa tg-..enter upon the above-described property for
inspection pur•• - I a.re4nbt to occupy or allow occupant of any uilding
.Aaauthorized 1r II final inspection.
/ / � 6 t.-.Dr A egalOwner(s) lcOate f,
S'g6
"L nattve— 1--..�G -
3057J613/07) Angor Authorized Applicant Dale
CITY OF COSTA MESA
4 BUILDING DIVISION
F ;A DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
PERMIT
4. -''1h•Ro'-.mm's°°
/B01-01655
(714)754-5273 • Fax(714)754-4856 • www.cLcosta-mesa.caus 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 129 BROADWAY Status: ISSUED
Suite: Applied: 10/18/2001
Vicinity: Issued: 10/18/2001
Parcel Number: 42545121 Zoning:
•
Applicant: MC CLELLEAN, MITCH ISSUED BY:
Address: 25434 MORNINGSTAR RD .. "
',„:7./2 Phone: 949-581-5269
LAKE FOREST,CA / - Zip: 92630
��.
Owner: MEREDITH;DAVIDAND LAURI
Address 23232.PERALTA DR " - / ' ` N.
,SUITE 105 - 1 - Phone:
LAGUNA HILLS;CA ' - Zip: 92653
Contractor `M &M"ROOFING�
Address:. 25434 MORNING STAR RD ,
Phone: (949)581-5269 ,
LAKE FOREST,CA -
Zip: 92630 ' •License: 737040
Arch : - _ — - - Eng: . ,
Address: Address:
. " Phone: -
'Zip: 'v License: - 'License:
_ SCOPE OF PERMIT
TEAR OFF GRAVEL ROOF DOWN TO SHEATHING, REPLACE BAD WOOD, 1 BASE,2 PLYS AND ROCK. NEW FLASHINGS,
NEW GRAVEL STOP.TOP PORTION OF TRIPLEX ONLY. -- -' - - - - ` . -"
FEE SUMMARY
,Plan Check: $0.00 - - -- - - - Calc Valuation: $3,000.00
Permit: $83.25 • Claim Valuation: , $3,000.00
,SMIP Res: $0.50
SMIP Corn: $0.00
Other $0.00 ..
'Inspection: . -$0.00 ,. •• ,
Total: $8315 - . - .
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(WOO)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby a under penalty of perjury one of the following declarations:
0 ave 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'compensatlp`�yn ur ce carrier and num r are: /'
Cartier: l� T, Policy Number: IS 67— /3EO
(This section need not be completed if the permit is valued et 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 agr is that if I should become sub/er1�to the workers'compensation provisions of Section 3700 o the Labor e,I shall forthwith
comply with these provisions.
Applicant Signature: 4416
/f✓ Date: g/ v
I
WARNING:FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DECLARE(S100,000),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 ' ' ns of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions e,and my license is in full
force and effect.Lia N • / I1N' 0 Class# /C) [ _flat
Contractor's Signature: /IN�--ole 1i1/L( ..... 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 end the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a perrr4'
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 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).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? d 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 hes 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 compiled 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 a ermlt for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LI 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 a al(�vner( � AV/ {r/Ole
And/Or plicant O ( Datea
SODS t INSPECTION TYPE DAIS NRRIALE CODFE INSPECTION TYPE 2IE IIS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final � 208 Final Plumbing
/0-it-Fel
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
i3-522 e. 1 5 3/27/78 287x00 ,TL
_
•
COSTA MESA BUILDING-SAFETY DEPARTMENT d
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely — Use Ink Only
RECEIVED BY DATE RECEIVED DATE ISSUED
BUILDING /4 9 0,i(eADwil� Can, / /
OWNER7if M CCR/Nt A.P.NO. /!T�/O 3 -- PERMIT NO.
MAIL ``�� /1 BUILDING 707riffeyer rAy C.in
ADDRESS/Y7,��414/04 ADDRESS c1�1 fo77rt5
CITY `a'Td McS,a NE0 9/7E/O TRACT '-'T BLOCK
CONSTRUCTION NENf ADD ALTER REPAIR MOVINf: nFMn11SH
LENDER J
BRANCH \,N1 /�.o ,,-,/
OWNER �l" {\ t,\I rnL '
ADDRESS `ptnALUE
ARCHITECT \ TEL. ,1" '! $
OR ENGINEER ici L UQ ANS NO.4 3 70/O
/ FIRE
ADDRESS 33 5/--T A/Ea.9pn.T ,11/,,,P7 ZONETYPE GROUP
APPROVED Y
CONTRACTOR -./G1ra l,(,/c Itr Ae• $ BY / OATE
ADDRESS J4'yJ/ 739,14 C.6- Way
TEL/. ZONE NO.OF USE OF NEW
2 ,..-1102/6
CITY S,Vq/ Ca NO.73/.5/} r7/ n- PLANS V BUILDING
ma I^ STATE CITY YARDS APPROVED YARDS APPROV
LIC.NO. /6914 Z LIC.NO.®a F//C MAIN BUILDING ACCESSORY BUILDING
9,1 SIZE ✓, NO.OF BLDGS��
0c .j(FROM C/L STREET/
. OF LOT 4.7.j g x /as- ON LOT 44 R ��//
ONT FT. /i'OFT.
Q USE OF
4 EXISTING BLDG. NO sl,C_ R.SIDE FT. 19
FT.
V)F Separate permits are required for L.SIDE FT.,a FT.
electric,plumbing and heating work. _REAR FT. FT.
(.. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN& ._ /
OQ MAIN BLOCS. ACCESS BLOCS.
7pI6X C.ARU.V .#P.# Ci 2�z6. n8]
� .2- DATEAPPROVEDD I m
.� l
Q / `
'1 -7 (�f
A PROVF$', ;rjib C/ DATE 3/71 7 es
m . . . .Ln, IIT Km Cl)I�t'lB t R6ryl g- x . ::_: .. r5
0.. I herebyacknowledge that I have read this application and state --— 'n
IX that the above Information Is correct and agree to comply with
C• all laws regulating building construction, and I shall not employ
Z any person in violation of the workman's compensation laws of EI
T the State of California. m
I hereby certify that I am properly licensed as a contractor under SQ. FT. Cl
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9, a•d hat such licenses are In full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:ONte
—q
am exempt reit the provisions of the State of California Business VALUATION PERMIT FEE $ fV ,
and Profess'.ns ode, D ision 3, •apter 9. _�O r/ u5
r m
PLAN CHECK § m
Signature of _ c
_ LL
Permittee `...ate 1 $ TAX s
`,_ 11 f
//////
i Authoriz.t -- ' TOTAL PAID S. /' po U
._ 4 a 5 2 2 5998 2/16/78 19 .1 TL
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
A P CATION FOR STRUCTURAL PERMIT
For Applic dl•inn Completely— Use Ink Only R E lYt/`BV DATE RECEIVED DATE ISSUED
BUILDING
SROSIDIt7NN
ADDRESS /
PERMIT NO.
OWNER 4;k n 671.-king/4-y A.P. NO.
MAIL g
/V fi2 s/ Mint?i/ ./ BUILDING
•
ADDRESS jljj �'t ADDRESS
I•I
TEL
CITY S44f7A j44 NO�17'7OGI TRACT LOT BLOCK
CONSTRUCTION r NEW ADD ALTER REPAIR MOVING DFMOI ISH
LENDER Mpfcfh/E2 S4UWNG
BRANCH piaci peIT T3�'Hc.i . / �r�r
OWNER Ohl/ / C /C/�/„I 1.-
ADDRESS ARCHESS Tear c /" IdD 1
ARCHITECT �p TEL. USE s x047 au
OR ENGINEER ^19Y AF✓s7^/It.S NO. c 7$'-7p0/OFIRE �/f _
ADDRESS Ss yr" AtrortraIVD 4. .[J. ZONE TYPE / _ GROUPH¢J
�-} APPROVED
CONTRACTOR /pjn Jit/E*444 BY DATE
ADDRESS 7// 73aAIec (otos.
TEL. ZONE NO.OF USE OF NEW
CITY Tin//A/ r a�,Po. NO. PLANS BUILDING —
F STATE CITY YARDS APPROVED YARDS APPROVED
v. MAIN BUILDING ACCESSORY BUILDING
LIC. NO. /69 Re e• LIC.NO.
{,y I SIZE / NO.OF BLDGS. (FROM CIL STREETI
6. OF LOT 64/ ,( /2 r NOW ON LOT C) ONT FT. FT.
yUSE OF t
EXISTING BLIX3• _ 6.3129 FT. FT.
rn
PE I-0
Separate permits are required for L.SIDE FT. FT.
electric,plumbing and heating work.
WREAR FT. FT.
Q
USE OF BUILDING AND WORK"7k
TO B PERFORMED�.rL SLOGS.
BET. BET.MAIN& \__ 1
Q 7 i p Li 4 Pt cin72l MAIN BLD . ACCESS.BLDGS.
VAR.9♦'+ DATE
Q / �/��gy i 5(„i�•/r� '� C.U.P.# APPROVED
7 //! -'-r APPROVED
>• BY DATE
IX
L
0 I hereby acknowledge that I have read this application and state
N
C4 that the above information is correct and agree to comply with
L all laws regulating building construction, and I shall not employ :
Z any person in violation of the workman's compensation laws of o
W the State of California. �•-sr -
//'y ¢/y z /// x{71
I hereby certify that I am properly licensed as a contractor under �/ // SO. FT. ��� .�/ co
the State of alifornia Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR re
Chapter 9, that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exempt, the provisions of the State of California Business �O
and Profess'. •-Code,01,.Ion 3,Ch tar 9. r VALUATIONtoo PERMIT FEE $ , r•Hy
Signature of � (/ / — /�] /p�r
e..-PI" ,,�r.F Ej' ^_rL.
Permittee """���"'11Y��iRF///llltt�(f r it P TaI(J''/(D/J n "•`f7r6�
TAX ,1 $ bill- 'Lug
Author's- ant ( 1 LJA TOTAL PAID i...dr li
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely —Use Ink Only
RECEIVED BY DATE RECEIVED DATE ISSUED
ADDRESS
BUILDING /27 eael4.6 4iy
/ .4/G/j
/NEEP PERMIT NO.
OWNER / A.P.NO.
MAIL BUILDING
ADDRESS ADDRESS
TEL.
CITY • NO. TRACT 1 LOT BLOCK
CONSTRUCTION NEW (ADD ALTER REPAIR (MOVING DFMOI ISH
LENDER
BRANCH
OWNER
ADDRESS VALUE
ARCHITECT TEL. USE $
OR ENGINEER NO
FIRE
ADDRESS ZONE TYPE GROUP
APPROVED
CONTRACTOR BY DATE
•
ADDRESS ZONE INO.OF USE OF NEW
TEL. PLANS BUILDING
CITY NO.
F• STATE CITY YARDS APPROVED YARDS APPROVED
LIC.NO. LIC. NO. MAIN BUILDING ACCESSORY BUILDING
W SIZE NO.OF BLOCS. (FROM C/L STREET)
b. OF LOT NOW ON LOT FRONT FT. FT.
Q USE OF
.S., EXISTING BLDG. R.SIDE FT. FT.
V)
I-.
Separate permitsarerequired for L.SIDE FT, FT.
electric,plumbing and heating work.
W - REAR FT. FT.
I-. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
-C n/ rr MAIN BLDGS. ACCESS. BLDGS.
/•--� / t,{. VAR.. AATE
PPR
J /[J L1 C.U.P*W APPROVED
APPROVED
#1 —ELY DATE
FC
W
M.
I hereby acknowledge that I have read this application and state N
Sthat the above information Is correct and agree to comply with m
all laws regulating building construction, and I shall not employ
Z any person in violation of the workman's compensation laws of o
1,11 the State of California. �/J /j A�mi: �1 = J m
I hereby certify that I am properly licensed as a contractor under / , ! SQ. FT. / (G w
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
vz
am exempt from the provisions of the State of California Business VALUATION PERMIT FEE $
e
and Professions Code, Division 3,Chapter 9. n
PLAN CHECK $ /84�00 o
Signature of ei IL
Permittee $ /00,adt� TAX $ -7eQ O IL
Authorized Agent TOTAL PAID $ /91.00
v.
• r ,„ rD60o 9041 4/12/76 23013 TL
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
AP A ION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely — Use Ink Only
REC I E V DATE RECEIVED
DA EE ISSSUE "ASG i /"2 I�
ADDRESS / t 9 jigROwU4JA7
^� ^�
1
OWNER —SOkM ae/r.,IE,, A.P. NO. I 1— 'O�—',%/f/s�,l/}/� yf�,/�
MAILBUILDING /in ,lo/""'^ —e•e
ADDRESS /gy/� '�AryYl9/CR ADDRESS f /y O/
TEL. TRACT LOT BL CK
CITY C NO.
nSTA h'/arSq
CONSTRUCTION NEW A /D,
DALTER REPAIR MOVING' DFMOLISH
LENDER kvale/al EIC _ /X`
BRANCH .
OWNER /
ADDRESS / e. l' / VALUE L=
ARCHITECT TEL. USES i
OR ENGINEER F�aY hA l/E/t/ Cl NO
FIRE
ADDRESS ZONE ROU F
CONTRACTOR�O APBY DATE tie/2 -7G
ADDRESS /.a7// PA /peg, 4045/ • Z NE NO.OF USE OF NEW� /TEL. PLANS BUILDING f'�
I'• CITY ILLS—; Cg NO.7.31_449' —Z W^ �—
�-r
STATE CITY YARDS APPROVED YARDS APPROVED
LIC.NO. 16 9 Pr`7 LIC.NO. dA/Fi/C MAIN BUILDING ACCESSORY BUILDING
DI SIZE NO.OF BLOCS. (FROM C/L STREET)
S OF LOT I NOW ON LOT FRONT FT. FT.
*IC USE OF • r p`
4 EXISTING BLDG. Nemo Tit P/E'1` R.SIDE `U`fN1M SFT.
rn 1 03)1/4'
t-,
Separate permits are required for L.SIDE /� FT. FT.
electric,plumbing and heating work. 1
DIREAR FT. FT. ' Th
I.., USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN& _
Q MAIN BLOCS. ACCESS BLOCS.
G_ /Z §.--• a40tJC 4+4 l 4Y f{CG r! AZC1 / y
DATE
CU .# — o)
APPROVED 11/24/77
Q
.'.1
CC
APPROVEDxi, DATEiti 1-L1788
lY�
O I hereby acknowledge that I hove read this application end state 'n
g4 that the above Information Is correct and agree to comply with m
Z. all laws regulating building construction, and I shall not employ e:
Z any person In violation of the workman's compensation laws of o
Sthe State of California. m
I hereby certify that I am properly licensed as a contractor under SO. FT. r
the State alifornia Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9 a that such licenses are In full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exemp f m the rovlsion f the State of California Business VALUATION PERMIT FEE $ lStn
and Profes o s Cod 'vision?, hapten 9..
/n/ PLAN CHECK $ in
Signature
I,
Signature of // /�` /� - / G
Permitt 4 !" $ /i7 ee TAX $ I Lel If
�/!/V e U
Authori Agent TOTAL PAID E 2. eo ',
3
I
GRIMPROJE ADDRESS: 13L 1 EY,BROADWAY
JOHN uxlT: CITY OF COSTA MESA - BUILDING PERMIT PERM NO: R 063299
OWNER'S NAME:
ADDRESS:
%LISA, MICHAEL PERMIT NO; B 063299 PLAN CHECK NO: N GOVT: N SUPP: N
9187 NADINE RIVER CIR
FOUNTAIN VALLEY, CA 92708 CONSTRUCTION TYPE: 5-N PERMIT TYPE: STR PURPOSE: ALT
rARCK/ENGINEER: '346-9950 REG.NO.: JOB DESCRIPTION : RE-ROOF W/FIBERGLASS COMPOSITION SQ FT; 2, 375
ADDRESS: UNIT:
PERMITTEE: CLAIM VALUE; 2, 375 . 00 CALC-VALUE: 2, 375 . 00 GROUP OCC: R-3 /M-1
ADDRESS:J 9• EHIWESN VOOFING, CO, ( '114 )730 3443 at� E .W -TEgTpR
IA991 HEWES AV COMMENTS; SMOKE DETECTOR(S ) REQUIRED IN HOME, REOOF 23005F u
SANTA ANA CA 92705 ********************N�F�F�F�e****,t **** *** � *** ********X***** IN. . 4. i*A-. **
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTS
70001 of Division 3 of the Business and Professions Code,and my license is in lull force and effect. REQUIREDSETBACKS
CITY LIc.:029639 STATE uc.:3 is . J CLASS: _.49
Date: O-3-43 Signet. .. _ MAIN BUILDING ACCESSORY BUILDING
WORKERS'COMPENSATION DECLARATION: I hereby affl • at I have a certificate of consent to self-insure or a certificate of Workers' FRNT: FT IN REAR: FT IN FRNT: FT IN REAR; FT IN
Compensation Insurance.or a certified copy thereof(5e r 3800.Lab.C). LEFT; FT IN RGHT; FT IN LEFT: FT IN RGHT: FT IN
POLICYN0.:285-93-UNTT90 XP.°ATE: 01 /01 /94
. ,c°MPANY:STATE FUND_ PARKING REQ• PROV: PARCEL; 4254SF21-- ZNE; REF NO:
3 Cenified copy is hereby furnished. }F Certi d copy r fit d with the city Building Division. PLANNING NOTES> `-
22
c) Date: -J�^ 7//�A J Applic n. **************>*********************************3F*******************************
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: ,is section need not be completed if the permit is for ane hundred(51001 or less). D E V 'E L O P M E N T SERVICES'1CREQUIREMENTS
I certify that in the performance of the work for which this p It is issued,I shall not employ any person in any manner so as to become r
subject to the Workers'Compensation Laws of Californi . ZONING APPROVED BY DATE:
Date: Signator •
NOTICE:If.after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY : ( - . DATE
Code.you must forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED B Y• -,e,71_ " DATE; 1
which this permit is issued(Section 3097.CM.C). *****************************************ye* *fe******-****!E*it****%it* Kt*n•fe x%•***
LENDER: *********************************************** F *************!h***Kx***********
ADDRESS: LEGALIZATION: N F E E SUMMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve.demolish.or PERMIT 54 . 00 5 0
repair any structure.prior to its issuance.also requires the applicant for such permit to file a signed statement that he/she is licensed
pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business SM I P/NON—RES
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN `
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). ISSUE FEE
I. as owner of the property or my employees with wages as their sole compensation, will do the work, and the BUILDING-DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law TOTALS----> 54 , 50 0 , 0 0 0 . 00 5 4 , 5 0 54 , 50 , 00
does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through ,P'
his or her own employees.provided that such improvements are not intended or altered far sale. IL however the building or
improvement is sold within one year of completion,the owner will have the burden of proving he/she did not build or improve REVENUE DIVISION TOTALS--> COLLECTED; 54 . 50 OVER/SHORT• . 00
tor the purpose of sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SHIP/TOT GRADING PLAN-CHECK
I,as owner of the property.am exclusively contracting with licensed contractors to construct the project(Section 7044.Business 54 , 00 ;.,50
❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon ,-
and who contracts for such projects with acontractor(s)license pursuant to the Contractors'State License Law).l am aware .K,*****.*,******.****************************.*****jE9(-******** ******************K-***
that proof of their Worker's Compensation insurance should be provided to me.
❑ I am exempt under Section: B.8 P.C. INDIVIDUAL F E E BREAKDOWN
for tn¢mason: TYPE QTY D E S C R I P T I f }N UNCOST TOTAL COST
Dale: Owner: ,,3��-,,
I do hereby cenify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505.25533.and SFR C>>75 REROOF BY VALUE R Ej ENDIDOFI FEESAL 1 . 00 1 , 0 0 2., 3 7$ , 0 0
25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a SE
permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt fromE XP I R E D '
these provisions. P1
IncOmplete Inspections
Dale: Applicant: 1
I hereby certify that I have read this application and stateihat the above information is correct.I agree to comply with all city and county ! /V}71� �I] i {'
ordinances and state laws relating to building construe',n and h. .by authorize representatives of this city to enter upon the above-mentioned aha 61 -Sig — ^
property for inspection purposes. I tJMW U f, y
3 ,t
c \ Date: F-- - 9 Signature: .- /
/ ?}. 01 00103036-0B_1440 7 TOT 54.50
7 2
Driver's License or Social Security x.: ,-. is
1641-46 White-Budding,Green-Code Enforce (Canary-Applicant;Pink-Revenue:Goldenrod-Assessor 666
•
CQNSTRUCTION AND PLANNING - - POC SPA
LAPPROVALS Permitrfr Date Inspector APPROVALS Permit Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility"Undrgrnd. 54. Forms
4. Peet:real Conduit-Undrgrnd. 55. Electrical Bono n;
5. StLc leinforcement 56. Rough Plumbing & Pressure Test
3. E:irctr.cai UFER Grnd. 57. APPROVAL TO COVE R-GUNITE
7 Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, 0 Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewn Cap 63. Heater& Vent-Final
} 13. Roof Drains 64. Plumbing System - Final
•
14. Rough Plumbing 65. Electrical-Final
15 Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
~18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
29. 9a_un Factory Fireplace APPROVALS Permit V
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank C7 Gas 0 Oil
1_25. Roc: Sheathing 74. Cverhead Hydro
26. T-B rr Ceiling (Structural) & i.1onocoat 75. Dry Chemical -
27. Frame aril Flashing 76. Dry Standpipe -
28. Lathing & Skiing 77, FIXED SYSTEM FINAL 7•
�•
29. Insulation I I 78. FIRE PREY. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT v .
31. Piaster Brown Coat 1 79. FINAL INSPECTION
32. Ei ctrica' Power Meter-Final ! 80. FOOD CERTIF ICATE ISSUED __
1 '
33. Final Electric Notes:
34. Final Heating& Air Conditio,mg
35. Final Gas Pipe-Test
36. Hood or Canopy i- - -_
X-P_I_P E-d ,
_�__ ;
37. Final Factory Fireplace Prot
e 7 chs,,,, -
38. Final Plumbing pate '1N.
33. Water Service-Final { -
40. Gas Service-Final O r •
L41. Solar Domestic-Final t
ti.
42. Backflow Preventer Q=C� q3 - Q � - k-c _rmm"j[ -
�ty
43. Backflow Irrigation 0 ✓ taut c
_ 44. Landscape Irrigation System t'�
45. Sound Attenuation _
4S. Handicap Regulationsl'`:
47, FINAL STRU'CTURE`•&+SUILDING
48 FINAL PLANNING -
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
(