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Home My WebLink About480 SHADY DR - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: Suite No Vicinity: Parcel Nunmber: 480 SHADY DR SFD 11737251 Applicant: BURDEN, DEBRA Address: 480 SHADY LN COSTA MESA, CA Owner: BURDEN, DEBRA Address 480 SHADY LN COSTA MESA, CA Contractor: OWNER -BUILDER Address: ELECTRICAL PERMIT Phone: 949-640-7355 Zip: 92627-3228 Phone: Zip: 92627-3228 Phone: Zip: License: 000000 Status: ISSUED Applied: 02/13/2003 Issued: 02/13/2003 ISSUED BY: SCOPE OF PERMIT ELEC PERMIT IN CONJUNCTION WITH CONSTRUCTION OF A 448 SF ADDITION WHICH INCLUDES THE 368 SF EXPANSION/RELOCATION OF THE MASTER BEDROOM/BATH, AND OF BEDROOM #3 IN AN EXISTING SINGLE -STORY SFD. THE ENTRY WILL BE EXPANDED BY 80 SF AND REMODEL OF THE NOOK, BEDROOM AND BATHROOMS AT THE REAR OF THE RESIDENCE. A FIREPLACE (WK #632217700) WILL BE ADDED TO THE MASTER BEDROOM. 34 LIGHT FIXTURES, 35 OUTLETS, 14 SWITCHES, 1 SERVICE TO 200A. REF: B03-00125 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway /100 It $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kva/kw $0.00 0 Lighting Fixts $32.22 34 .................up to 50 kva/kw $0.00 0 Recept Outlets $32.95 35 .................up to 100 kva/kw $0.00 0 Switches $15.40 14 ..................over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $30.50 1 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 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 2"6-46 leant DECLARATIOMS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: " ❑ 1 have and will maintain a certificate o1 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 maintaip 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 carder and policy number are: Carder: Policy Number: (This section need not be completed N the permit is valued at one hundred dollars ($100) or less.) ❑ 1 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 o1 the Labor Code, I shell forthwith 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 DOLIARE ($1000D0), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEYS 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. LJc. q Class M Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 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. 70", Business and Professions Cade: 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. IL 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 I ` 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 axe tun r sec. Business and Professions Code for this reason: Signature: A _ / Dat p Owner ID verified b drivers license. es ❑ No Drivers License No. Expire Verification of Ownership by (type of document, i.e. - property tax bill or dead): 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 material? ❑ Yes ❑ No (Section 25505 o1 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? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some excepdons, 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, codification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................................... ......... .................................. ............... ...............................-............................ ............ ............ .............................................................. ...................... ........ ............................................................................................ 4 It en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ONO ............................._..............................................................................................._...__.......................__........................-..........................._._.........................................................................................................................................._........ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agent. 5 Yes 8 No (Section 65B50.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ................................_.................................... ____............................................................_........................ __............................-_............................_._............................................ .............-....... 6 Will an ry p ...... ............... ....................... ........ y pen of the facili to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia 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? ❑ Yes ❑ 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 pr dy r insp on purposes. I agree not to occupy or allow occupancy of any building authorized b his permit until final inspection. O ��./1, - �-/3-403 Si nature Of Legal Owners) Date And/Of Authorized Applicant Date CODE I, INSPECTION TYPE SAS CODE. INSPECTION TYPE 2AN 11lTITIELS 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 (714) 754-5273 • Fax (714) 754-4856 • www.ci.00sta-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 480 SHADY DR Suite: Vicinity: REAR OF THE SFD AND ENTRY Parcel Number: 11737251 Zoning: Applicant: BURDEN, DEBRA ISSUED BY: Address: Phone: 949-640-7355 Zip: Owner: BURDEN, DEBRA Address 480 SHADY LN Phone: COSTA MESA, CA Zip: 92627-3228 Contractor: OWNER -BUILDER Address: Phone: Status: ISSUED Applied: 01/27/2003 Issued: 02/13/2003 Zip: License: 000000 Arch Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT CONSTRUCT A 448 SF ADDITION WHICH INCLUDES THE 368 SF EXPANSION/RELOCATION OF THE MASTER BEDROOM/BATH, AND OF BEDROOM #3 IN AN EXISTING SINGLE -STORY SFD. THE ENTRY WILL BE EXPANDED BY 80 SF AND REMODEL OF THE NOOK, BEDROOM AND BATHROOMS AT THE REAR OF THE RESIDENCE. A FIREPLACE (WK #632217700) WILL BE ADDED TO THE MASTER BEDROOM. LOT SIZE - 8,500 S.F. BLDG. COV. - 2,965 S.F. PAVING - 1,770 S.F. OPEN SPACE - 3,765 S.F. (44 %) FEESUMMARY Plan Check: $129.63 Calc Valuation: $71.395.20 Permit: $797.75 Claim Valuation: $0.00 SMIP Res: $7.14 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $934.52 PLANNING & ZONING 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 IBM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by sectlon 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ 1 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 cancer and policy number are: Carrier: Policy Number: (This section need not be completed If the permit /s valued at one hundred dollars ($100) or less.) ❑ 1 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 forthwith 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 PINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST. AND ATTORNEYS 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. Uc. a Class a Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 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). Lenders Name: Lenders Address: Signature: Data: 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 Dlvisim 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 cMi penalty of not more than two 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 ex 1 and sec. Business and Professions Code for this reason: P Signature: ,,{.,:�� /NJ pto: _ 015 Owner ID verified by drivers license. -a ❑ 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 permll, 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 6, 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 WIII 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? ❑ Yes ❑ 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? ❑Yes ❑ 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 appplicant or present or future building occupant need to prepare an RMPP (Risk Management antl 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 Dopartmenl of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...................................................................__._..._..._..............................................................._......................_..........................................................................................._..... ........................_._............ _._............. __........... _. 4 II an RMPP is presently required, has Section 25534 of the California Health and Safety Cade been fully . complied with? ❑ Yes [I No ........ .........................................................................................................................................................................................................................................................._.._............_.._._......................_.._............_............................._. 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this as placation aemit 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 Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................................................................................................................................................................................................................................................................................ ....................................._......................................_.......... 6 WIII any pert of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ 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 Oueli . 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 prescrlbed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .......................................................... ............................................ _........ ........................................ ........ ... ............................ ................................... ..................... ........................................................... .............. _._............ .._.............. ..__........... 6 (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 abovedescrib roperry for iospec'� 1 purpose I agree not to occupy or allow occupancy of any building authorized by this permit until ligel i action. �../ ICW_xbignalure Of Legal Owners) �,n[,— 3 Date/✓C And/Or Authorized Applicant Data CODE.. INSPECTION TYPE l� RfittlAs CODE INSPECTION TYPE ILL$ 1616 Fixed System Final Fire Prevention Y✓ 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Rool 210 Final Electrical 201 Final Block/Relaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 20Final Sign 2Final Site 204 Final Demolition 25050 Final Budding/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 480 SHADY DR Suite No Vicinity: SFD Parcel Nunmber: 11737251 Applicant: BURDEN, DEBRA Address: 480 SHADY LN COSTA MESA, CA Owner: BURDEN, DEBRA Address 480 SHADY LN COSTA MESA, CA Contractor: OWNER -BUILDER Address: Arch / Eng : Address: PLUMBING PERMIT Status: ISSUED Applied: 02/13/2003 Issued: 02113/2003 ISSUED BY: Phone: 949-640-7355 Zip: 92627-3228 Phone: Zip: 92627-3228 Phone: Zip: License: 000000 Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT IN CONJUNCTION WITH CONSTRUCTION OF A 448 SF ADDITION WHICH INCLUDES THE 368 SF EXPANSION/RELOCATION OF THE MASTER BEDROOM/BATH, AND OF BEDROOM #3 IN AN EXISTING SINGLE -STORY SFD. THE ENTRY WILL BE EXPANDED BY 80 SF AND REMODEL OF THE NOOK, BEDROOM AND BATHROOMS AT THE REAR OF THE RESIDENCE, A FIREPLACE (WK #632217700) WILL BE ADDED TO THE MASTER BEDROOM. 3 BATHTUBS, 1 GAS OUTLET (1-4), 1 SHOER, 1 WASH BASIN, 2 WASH BASIN SETS, 3 WATER CLOSETS. REF: B03-00125 FEE SUMMARY ANT CITY AMT ISSUE FEE $23.50 Laundry Tub / Washer $0.00 Backflow, irrigation $0.00 0 Landscape Irrigation $0.00 Backflow Preventer $0.00 0 P-Trap $0.00 Bathtub $29.40 3 Pressure Regulator $0.00 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 Dental Units $0.00 0 Septic Tank $0.00 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 OTY AMT CITY 0 Sump Pump $0.00 0 0 Swimming Pool $0.00 0 0 Trap Primer $0.00 0 0 Urinal $0.00 0 0 Vacuum Brkr Bkflow(1-4) $0.00 0 0 Vacuum Brkr Bkfow(5+) $0.00 0 0 Wash Basin $9.80 1 0 Wash Basin Set $19.60 2 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 2"646 (8=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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. ❑ 1 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: I Policy Number: (This section need not be completed if the permit is valued atone hundred dollars ($100) or less.) ❑ 1 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 forthwith comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUaJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOULARE th 00.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70DO) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. 4 Class k Contractors 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). Lenders Name: Lenders 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 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.). 1, 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 exe 1 uncle/�5ec. Business and Professions Code for this reason: Signature: �.e L �a — /L ate: _ Owner ID verified by driver's license. Etlas ❑ DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 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, All 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 material? ❑ Yes ❑ No (Section 25505 of the Califomia 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 standarG temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration loan for acutely hazardous materials? ❑Yes ❑ No (Section 25533 01 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 feel 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? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject this a placation a ppermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes u 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? ❑ Yes ❑ 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? ❑ Yes ❑ No ............................... ............ -................................... _............................................. I. ................................. ............................ ...................... ............................... .......... ................................................................. .......................... ................................ . 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 pro for in action oses. I agree not to occupy or allow occupancy of any building authorized Dy this�mit u inspection. Signaturil 07 Legal Owner(s) Date And/Or Authorized Applicant Date CODE I. INSPECTION TYP INITTAL CODE r INSPECTION TYPE g/M INTRIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 11� 1266 Pool Spa Final 208 Final Plumbing ' j - O 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Well 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 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 480 SHADY DR Status: ISSUED Suite No Applied: 02/13/2003 Issued: 02/13/2003 Vicinity: SFO Parcel Number: 11737251 ISSUED BY: Applicant: BURDEN, DEBRA Address: 480 SHADY LN Phone: 949-640.7355 COSTA MESA, CA Zip: 92627-3228 Owner: BURDEN, DEBRA Address: 480 SHADY LN Phone: COSTA MESA, CA Zip: 92627-3228 Contractor: OWNER -BUILDER Address: Phone: Zip: License: 000000 SCOPE OF PERMIT MECH PERMIT IN CONJUNCTION WITH CONSTRUCTION OF A 448 SF ADDITION WHICH INCLUDES THE 368 SF EXPANSION/RELOCATION OF THE MASTER BEDROOM/BATH, AND OF BEDROOM #31N AN EXISTING SINGLE -STORY SFD. THE ENTRY WILL BE EXPANDED BY 80 SF AND REMODEL OF THE NOOK, BEDROOM AND BATHROOMS AT THE REAR OF THE RESIDENCE. A FIREPLACE (WK #632217700) WILL BE ADDED TO THE MASTER BEDROOM. 1 INST FAU < 100K BTU, 1 FACTORY FIREPLACE. REF: B03-00125 FEESUMMARY Quantity Quantity ISSUE FEE $23.50 Repair / Alt Absottlon Unit $0.00 0 Inst FAU <100 k BTU $14.80 1 Repair / Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair / Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst / Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys >100 k BTU $0.00 0 Compressors / Absorption Systems Gas Piping MIX) 0 Up to 3 hp / 100 k BTU $0.00 0 Factory Fireplace $10.65 1 3 To 15 hp / 500 k BTU $0.00 0 Hood w/Mech Exhaust $0.00 0 15 To 30 hp / 1,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp / 1,750 k BTU $0.00 0 Vent Fan / Single Duct $0.00 0 Over 50 hp / Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee 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 2Ur,46(6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performanca of -the work for which this permit Is Issued. My workers' compensation Insurance carder and policy number are: Carder: Policy Number: (This section need not be completed it 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 provislons of Section 3700 of the Labor Code, I shall forthwith 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 CML FINES UP TO ONE HUNDRED THOUSAND DOI.LARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that l 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. R Class k Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 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). Lenders Name: Lenders 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 Lcense 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. 7D44, 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. It, 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 lot purpose of sale.). pd 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 a pl u er sec. Business and Professions Code for this reason: it 0 Signature — - Expires: e— Vedlication of Ownership by (type of document, Le. - 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 WIII 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? ❑ Yes ❑ 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). ......._.............._._..................._...._..................sent___..__._.___............................_...eed t..........."a"'r..._."t'!"o........._.__......_..._____.._.._............... ]-Yes.._....._...................._................_.............. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutey hazardous materials? ❑Ves ❑ No (Section 25533 of the California Health and Safety Cade, 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 SOD 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. ........_..............................._..................... .............................................. .............................................................................. .............. .... .............................. ........................................... ....................._...................................................................... a If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No ................................_..............................._............................................_...—_............................._..........................____................._._........................................................................_..............._....................................................._... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plicetlon aRpomit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agent)? 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). ......_..................................................................._..................................................................__.........................___........................_.................................__............................... _....I ......... __.................._................._................._........ 8 WIII any pert of the facility to be constructed under this permit be within 1000 teat from the outer boundaries of a school? ❑Ves ❑ 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? ❑ Yes ❑ No ........................................................................................................................................................................................................................................................................................................................................................................................... 8 (II "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 comp) with all state laws (Id city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -described grope r insp coon pum y or allow occupancy of any building authonzedthl. /3pelmit until finalpgGijon. Signature f Legal Owner(s) Date J/. And/Or Authorized Applicant Date CODE I. INSPECTION TYPE Q9$E RiIIDALS CODE E INSPECTION TYPE �+PAM_ (I� 1616 Fixed System Final Fire Prevention 206 Final Mechanical `� J� O U n / 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Well 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 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us NG PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 480 SHADYDR Status: ISSUED Suite: Applied: 10130/2000 Vicinity: Issued: 10/30/2000 Parcel Number: 11737251 Zoning: Applicant: PLANT, SUZANNE ISSUED BY: Address: Phone: 949-631-3836 Zip: Owner: PLANT, DEAN & SUZANNE Address 480 SHADY DR COSTA MESA, CA Phone: 949-631-3836 Zip: 92627 A i 1 Contractor: Q Address: Phone: Zip: License: Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT ADD INTERIOR PARTITION WALLS TO CREATE A BEDROOM AND OFFICE AREA IN AN EXISTING SINGLE FAMILY RESIDENCE, ADD BAY WINDOW IN OFFICE AREA. ADD A NEW WINDOW IN THE OFFICE AND BEDROOM. Plan Check: $54.11 Permit: $83.25 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $137.86 SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 ACCESSORY Front 0-0 Rear 0-0 PARKING Existing: 0 Required: 0 NOTES: FEE SUMMARY Calc Valuation: $2,500.00 Claim Valuation: $2,500.00 PLANNING & ZONING Left 0-0 Right 0-0 Left 0-0 Right 0-0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754,5626 2aa64e (woo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and wiaintain a�rtificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ,I �� ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the pertornanco of the work for which this permit is issued. My workers' compensation Insurance carder and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($too) 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 forthwith comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERSCOMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED MR IN SECTION 370fi OF THE LABOR CODE, INTEREST, AND ATTORNEYS 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. Uc. P Class M Contractors 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). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: 1 hereby affirm that unUeS pedally of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the fallowing reason (Sec. 7031.5, Business and Professions Code: Any city or county whichrequiresa 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 licerised'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 moro 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 Cade: 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 awn employees, provided that such improvements are not intended or offered for sale. It, 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 Ucen t apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pur ht to the C tractors License ws.). ❑ I a sec. Business and Professions Code for this reason: Signature Date: Own D veritia drive s license. Yes ❑ No Drivers License No. Ex res: Vert nerShip (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, An 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 certity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Cade 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? ❑ Yes ❑ 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 01 the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing With the Fire apartment of an RMPP by businesses which are required to registei acutely hazardous materials with the Fire Department. ..........................................................___.........................�_..._._._._................. CaliforniaHealth f................................................... ................._.._.........__............—_...._._..._—. 4 If an R M P P is presently required, has Section 25534 of the mia Health and Safety Code been fully complied with? ❑Ves ❑ No 5 Does or will the applicant or present or Future building occupant require for the work which is the subject of this a S plication ePeNo for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? � Yes 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? ❑ Yes ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the Califomia 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? ❑ yes ❑ No ........................................................................._._._........_.................._.........._...._......._...........................__......................................................................................................................_.__....._............_........__...._._.._ e (Ii'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- RIZATI F ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I egr o comply with all�Atate laws antl city oldi nces relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-d bed property for inspection purposes I ogre of too upy or allow occupancy of any building authorized byispemit unty fin inspection. gn f LegalOwner(s) 1 Date Anci/Or Authorized Applicant Date CODE 1. INSPECTION TYPE PATE III CODE1 INSPECTION TYPE PALE NITnA 4 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing -. 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Well 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 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 480 SHADY DR Suite No Vicinity: Parcel Nunmber: 11737251 Applicant: PLANT, DEAN & SUZANNE Address: 480 SHADY DR COSTA MESA, CA Owner: PLANT, DEAN & SUZANNE Address 480 SHADY DR COSTA MESA, CA Contractor: Address: Phone: 949-631-3836 Zip: 92627 Phone: 949-631-3836 Zip: 92627 Status: ISSUED Applied: 10/30/2000 Issued: 10/30/2000 ISSUED BY: 61 Phone: /t.�(Y�]/� Zip: b3 License: `a,1 _.� SCOPE OF PERMIT MISC ELECTRICAL FOR INTERIOR REMODEL. 2 NEW LIGHTS, 2 SWITCHES, 2 RECEPTACLES. 'p - moo - o 1 � L-E-S FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kva/kw $0.00 0 Lighting Fixts $2.20 2 .................up to 50 kva/kw $0.00 0 Recept Outlets $2.20 2 .... ....._...... up to 100 kva/kw $0.00 0 Switches $2.20 2 ..................over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0" Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Remspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $30.10 Intermed Pole $0.00 0 COMMENTS / SPECIAL CONDITIONS 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 2"6-46 (6/00) I DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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. ❑ 1 have and will maintain workerscompensation 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 it the permit is valued at one hundred dollars ($100) or less.) ❑ 1 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 37DO of the Labor Code, I shall forthwith 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 FINES UP TO ONE HUNDRED THOUSAND DOIJ.ARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lic. # Class # Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 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). Lenders Name: Lenders 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 ($500t): ❑ 1, 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 E%CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractor cerise Law o t apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) licen SUE t tot Contractors Ltcen a aw ❑ ai i _ is ec. -�' Business and Professions Code for this reason: Signatu . r Date: -Ow r'ID'veriti y driv is license:; - � � Yes ❑ No Driver's License No. Expires: Ve of Ownership by (type of document; Le _;property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 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 6, 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? ❑ Yes ❑ 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). ..e a applicant or or future Occupant need to file a registration form �f o�r ��rdous�m a t e ri I N ......................................... I.................. .............................. .. ..... 2 Does or will the Pp p building P 9 0 o acutely hazard a e a s7 ❑Ves ❑ o (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 Caste 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. ifiri-kW3i3, ................................................................................................................... ......,...........................................................................................................................................................................................--........................................ ............................................................................................. 4 Ii en RMPP is presently required. has Section 25534 o.. the California Health and Safety Code been fully complied with? ❑Ves ❑ No 5 Does will the applicant or present or future building occupant require for the work which is the subject at this a plication apertnit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes iPJ 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? ❑ Yes ❑ No (It'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? ❑ Yes ❑ No ..................�.............................v_.................................................................................................................................................................................................................................................. ................................................ e (If es', 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 COMP It AND AUTHOR TON OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. a to comply w hall state law rid ci ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the a -described property for inspection pure sea. gree not to occupy or allow occupancy of any building authorized by�his ermit until final inspection. r- __ fV� ISignature Of L al Owners) An-N—Or Authorized Date L-- AAurized Applicant Date CODE If INSPECTION TYEE BATE ItiIIRALS CODE INSPECTION TYPE UU INTRIAL;f 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 Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Buildmg/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us NG PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 480 SHADYDR Suite: Vicinity: Parcel Number: 11737251 Applicant: MACNEIL,TOM Address: 1835 WHITTIER AVE. COSTA MESA, CA SUITE F10 Owner: PLANT, DEAN & SUZANNE Address 480 SHADY DR COSTA MESA, CA Zoning: Phone: (949) 645-3917 Zip: 92627 Phone: 949-631-3836 Zip: 92627 Contractor: 21ST CENTURY ROOFING Address: 1835 WHITTIER AVE. COSTA MESA, CA Phone: (949) 645-3917 SUITE F10 Zip: 92627 License: 750385 Arch : Address: Phone: Eng: Address: Status: ISSUED Applied: 06/042001 Issued: 06/04/2001 ISSUED BY: (Ai: Phone: Zip: License: License: SCOPE OF PERMIT TEAR OFF COMP. INSTALL 30 LB FELT ON A 4:12 ROOF SLOPE AND 25 YEAR COMP. SHINGLE. 2900SF WITH ATTACHED GARAGE. FEESUMMARY Plan Check: $0.00 Calc Valuation: $4,500.00 Permit: $111.25 Claim Valuation: $4,500.00 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $111.75 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 "6-46(sroo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: , I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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: Cartier. Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ 1 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' e i CelifOmla, an e 1 sh Id b blect to the workers' co revisions of Section 3700 of the I shall forthwith mp y with these pro ( /L"a�bor/rode, l`J—iJ / Applicant Signature: Date: WARNING: FAILUR URE WORKERS' COA/PENSA— ERAGE WFUL PND SHALL SUBJ INAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED E($100,000), IN ADDITION TO THE COSTOF I ENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LIC5_RSEQeeNTRACTQRS DECLARATION: e nn t at I a licens nder pr ' io s of Chap r (commencing with Section 7000) of Division 3 of the Busine d Professions Code, and my license is in full orce and effect. Ll it Contractors Signature: Date: ING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for whichihie�p t- . (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 Cade: 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 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 contractors) 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. ❑ Yes ❑ 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 6, 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? ❑ Yes ❑ 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). ...................................................................................................................................................................................................................................................................... ...........................................................................I 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ 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 feat of compressed gas at standard temperature and pressure). ........ .................................................. _.___...................... __............................_.................... _..... ......_................................................................................................... ...... _.... ............ _................... ..................................... _ 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? [I 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? []Yes ❑ No .......................................................................................................................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aI Pff"It 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 Cade requires that the requested information be furnished on applications for non-residential building permits). .......................................................................................................................................__......................._..............................._........................................................... 6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ 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? ❑ Yes ❑ No ................. ................................................................................................................................................................................................................................................................................................................................................ 6 (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 "qnces relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -described property in ectj urp ;as. I gree no 0 occupy or allow occupancy of any building authorized by this permit until final inspection. cure L Date � lJT And/ Authorized Applicant Dat CODE r, INSPECTION TYPE INITIALS CODE r INSPECTION TYPE DATE INIMALB 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final � 206 Final Plumbing alll�e f 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Well 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 Applicant to fill in all spaces within heavy border lines and sign all appropriate declarations. -CITY OF COSTA MESA CONSTRUCTION PERMIT PERM I NO. - 05 TRACT NO. LOT NO.BLDG. NO. TYPE OF CON�SFRUCTION - -� ❑NEW [ ADD ❑ ALTERATION ' ❑REPAIR ❑CONVERSION ❑DEMOLISH ZONING REGULATIONS El A P $ DESCRIPTION OF WORK ' - ZONE PLNG. REF. qp Project Address Owner ��T/ �'r�� Phoneel/�e-Z5% Address Vdi -l�l1 if Arch/Eng. �f ��,() License No. Address %f1,3-iJ fl-// fTffEl'YI/ �fA/Cf. L'/% Contractor 4/-g y(Gj%$4.6Gz a;fd asphdne�33 ;i;38 TYPE OF PERMIT ❑GRADING ❑ FOUNDATIO.�INN ❑STRUCTURAL ❑ TENANT ❑ ELECTRICAL- V PLUMBING ❑MECHANICA ❑ OTHER a TToo 8PTtJRLpING SETBACK C T. PROPEfiTV LINE Address psN �, yQ.i,),a-1 r �, y'Z�0� SIOE YARD ' LS LICENSED CONTRACTOR DECLARATION 1 hereby affirm that I am licensed under provisions of Charter 9 (CORM- menting with section 7000) of Division 3 of the Business antl IEEDF ARID RIGHT REAR YARD (TO P/L) Professions Code, antl m license is in full force an effegL. -� L PROJECT DESCRIPTION PKG. SPACE REQ. PROVIDED License Class License N..�G .SQ. FT. OCCUPANCY —CONSTRUCTION TYPE VALUATION ZONE GRADING CU. YDS. ACRES Date Signature WORKERS' COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -Insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sects n 38 O Lai C.). ¢ > -�" /� �uu:Z Oro STREET WIDTH PARK FEE$ ZONING APPROVED BY DATE SPECIAL CONDITIONS: Policy No. Z_7 Company •-J/ _7 r_ GO ❑ Certified copy Is hereby furnished. ❑ Certified copy is filed with the city Building Division. EXEMPTION FROM WORKERS' COMPENSATION -DECLARATION REMARKS: _ l�! This section need not be completed If the permit Is for one hundred ($100) or less). - II certify that In the performance of the work for_which this permit is Issued 1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. PLUMBING PLAN CHECK ELECTRICAL PLAN CHECK BATHTUBS SHOWERS GARAut Date Signature NOTICE: If after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed TOILETS URINALS - GENERATOR 0-1 KW_1-10 KW TRANSFORMER APPLIANCE 10-50 KW_50 + KW LAVATORIES DOUBLE LAVS - revoked. CONSTRUCTION LENDING AGENCY KIT. SINKS DISHWASHERS MOTORS 0-1 HP_1-10 HP - SERVICE SINKS SUMPS I hereby affirm that there is a construction lending agency for the per- formance of the work for which this permit Is Issued (Section 3097 (INC. SOLAR) 10-50 HP 50 + HP FLOOR SINKS FLOOR DRAINS FIXTURES OUTLETS SWITCHES LenName - Lender's Lender's Address DRINKING FOUNTAINS GAS TUBE SIGNS OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for INTERCEPTORS CLARIFIERS POLE LIGHTS - the following reason (Section 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 re- qu improve, the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law Chapter 9 (commencing with Section 7000) of Division 3 of the SWIMMING POOL P TRAP POLES METERED SUB WATER SERVICE ALTERATION PANELS MAIN SUB GAS SERVICE OUTLETS SERVICE - AMP WATER HEATERS BTU OUTPUT usiness and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by SEWER CONNECTIONS any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). 7 I, as owner of the property, or my employees with wages as their SOLAR TANK COLLECTORS e compensation, will do the work, and the structure Is not intended offered for sale. (Section 7044, Business and Professions Code: The SOLAR PIPING SUS. ISSUE FEE .ontractor's License Law does not apply to an owner of a property who builtls or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not ISSUE FEE — APPLICATION APPROVED BY DATE MECHANICAL PLAN CHECK SUMMARY OF FEES - BUILDING PERMIT $ SMIP $ PLAN CHECK § PERMIT PLUMBING $ /D _ ISSUANCE $ GRADING $ PLAN CHECK $ ntended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner will have the burden of proving he did not build or improve for the purpose of sale). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to tr owner of property who builds or Improves [hereon, and who con- tracts from Such protects with a contractor(s) litesnetl pursuant to the Contractor'sLicense Law). HEATING SYSTEM 0-100000 BTU , AND DUCTING 100.000 + BTU REFRIGERATION 0-100,000 BTU SYSTEM 100,000 +BTU ❑ 1 am exempt under Section B. & P. C. for this reason ELECTRICAL $ $ MICROFILM $ PLAN CHECK $ TOTAL FEE $ MECHANICAL $ PLAN CHECK $ LESS AD - VANCEP PC $_ FINAL FEE $ /0. - BOILERS BTU Date Owner SYSTEM REPAIR, ALTERATION EXHAUST SYSTEM MULTIPLE 1 hereby certifythat I have read this application and state that the above information is correct. I agree to comply with all city and county and state laws1It relating to construction, and hereby authorize ze representatives tires of this city to ter upon the above mentionetl property property for �pR! ection puryo s. Signat ure'T L�i /A._!L: Qii Q- Date 'ISSUE FEE Drivers' L e or SS CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor CONSTRUCTION AND PLANNI G APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 43. Pool & Equipment Location 2. _ itPipe-Undrgrn 44. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrn 45. Forms 4. Eflectrical Conduit-Undrgrn 46. Electrical Bonding - - 5. Steel ein orce 47. Rough Plumbing & Pressure Test 6. Electrical UFER Grn 48. APPROVAL TO COVER-GUNITE 7. ootings _ 49. Electrical Conduit-Undr rn 8. Foundation 50. Gas Pipe, ❑ Undr rn, Test 9. Water Pipe-Undrgrn 51. Backwash Lines P-Trap.❑ ljrtlrqrn ' 10. Structural Floor System- 52. APPROVAL TO DECK 11. Property Sewer Line & House Connection 53. Backwash & Receptor -Final 12. Street Sewer Connection 54. Heater & Vent -Final 13. Rough Plumbing _ - ' 14. Rough Electric -Conduit _ 56. Electrical -Final 15. Rough Electric -Wiring - 57. Solar System -Final 16. Rough Heating & Air Conditioning - encing & Access Approval 17. Ducts, in Structure 9• APPROVED FOR PLASTERING 18. Ducts, Ventilating _ - 60. POOL/SPA SYSTEMS FINAL 19. Gas Pipe -Rough &Test 20. Roof Framing 21. Roof Sheathing NOTES: 22. Frame and Flashing 23. Insulation ' 24. Lathing & Siding 25. Drywall Nailing 26. Plaster Brown Coat 27. Electrical Power Meter -Final 28. Final Electric 29. Final Heating & Air Conditioning 30. Final Gas Pipe -Test 31. Final Plumbing 32. Water Service -Final 33. Gas Service -Final 34. Solar Domestic -Final 35. Landscape Sprinkling System 36. Sound Attenuation 37. Handicap Regulations 38. FINAL STRUCTURE & BUILDING 39. Special Requirements Completed 40. Electric Release to Edison 41. Gas Release to Southern California Gas Co. 42. CERTIFICATE OF OCCUPANCY No. Date PIP - Applicant to fill in all spaces within heavy border lines and sign all appropriate declarations CITY OF COSTA MESA CONSTRUCTION PERMIT PERM}�- *D /�' TRACT NO. LOT NO. [SLOG. NO. TYPE OF CONSTRUCTION ❑ NEW FADD ❑ ALTERATION ❑ REPAIR ❑ CONVERSION ❑DEMOLISH ZONING REGULATIONS ❑ OTHER A P DESCRIPTION OF WORK ZONE PLNG. REF. Project Address U a /J Owner C!4 Phone Address C� �'��'(y �,C, Arch/Eng. / U License No. Address �,�� -�A �O.5a A.) +PgCJAJS�13/'a/ Contractor &�' .. Phdn-,g TYPE OF PERMIT ❑ GRADING ❑ FOUNDAT�IO/NN' ❑ STRUCTURAL ❑ TENANT ❑ ELECTRICAL Kr LUMBING ❑MECHANIC ❑ OTHER Tp g�1ILpI G SET AC PROPERTY LINE Address 6 rG "ow * 4- I YARD LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (com- mencing with section 7000) of Division 3 of the Business and 5Ip Y RIGHT REAR YARD (TO P/L) Professions Code, a tl my license is In full force an ti Class ense No. PROJECT DESCRIPTION SO. FT' � ' +p OCCUPANCY_ CONST R UCTI ON TYPE PKG. SPACE REQ. PROVIDED License Date ZFs L Signature _ STREET WIDTH PARK FEES WORKERS' COMPENSATION DE L'ARATION ZONING APPROVED BY DATE I hereby affirm that I have a certificate of consent to self -Insure or a certificate of Workers' Compensation Insurance, or a certified copy VALUATION ZONE SPECIAL CONDITIONS: 'ereof (Section 3800, Lab. C.). GRADING CU. YDS. ACRES licy No. Company REMARKS: �/ J Certified copy Is hereby furnished. El Certified copy is filed with the city Building Division. EXEMPTION FROM WORKERS' COMPENSATION DECLARATION (This section need not be completed if the permit is for one hundred (E10 or'less). ' t? I cerfy 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. PLUMBING PLAN CHECK ELECTRICAL PLAN CHECK BATHTUBS SHOWERS Data Signature NOTICE: If after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed TOILETS URINALS GENERATOR 0-1 KW_ 1-10 KW TRANSFORMER APPLIANCE 10-50 KW_50 + KW LAVATORIES DOUBLE LAVS revoked. KIT. SINKS DISHWASHERS MOTORS 0-1 HP_1-10 HP CONSTRUCTION LENDING AGENCY SERVICE SINKS SUMPS I hereby affirm that there is a construction lending agency for the per- formance of the work for which this permit is Issued (Section 3097 (INC. SOLAR) 10-50 HP 50 + HP FLOOR SINKS FLOOR DRAINS FIXTURES OUTLETS SWITCHES CN. C.. Len er's Name Lender's Address DRINKING FOUNTAINS A2 GAS TUBE SIGNS OWNER BUILDER DECLARATION I hereby affirm that I am exempt from.the Contractor's License Law for INTERCEPTORS CLARIFIERS POLE LIGHTS SWIMMING POOL PTRAP POLES METERED SUB the following reason (Section 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 re- quires the applicant for such permit to file a signed statement that he WATER SERVICE ALTERATION PANELS MAIN SUB GAS SERVICE OUTLETS SERVICE AMP is licensed pursuant to the provisions of the Contractor's License Law 'Chapter 9 (commencing with Section 7000) of Division 3 of the WATER HEATERS BTU OUTPUT 'siness and Professions Code) or that he is exempt therefrom and the :Is for the alleged exemption. Any violation of Section 7031.5 by SEWER CONNECTIONS y applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). SOLAR TANK COLLECTORS ❑ 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. (Section 7044, Business and Professions Code: The SOLAR PIPING SYS. ISSUE FEE Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself or ISSUE FEE APPLICATION APPROVED BY DATE through his own employees, Provided that such Improvements are not MECHANICAL PLAN CHECK SUMMARY OF FEES BUILDING PERMIT E SMIP $ PLAN CHECK $ ��qq-- PERMIT ISSUANCE E PLUMBING E GRADING E PLAN CHECK $ intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner will have the burden of proving he did not build or improve for the purpose of sale). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct project (Section Business not apply to and Professions Code: The Contractor's License Law doeses not owner of property who builds or Improves thereon, and who con- tracts from such' projects with a contractor(s) Iicennetl pursuant to tracts the Contractor's License Law). HEATING SYSTEM 0-100,000 BTU AND DUCTING 100,000 +BTU REFRIGERATION 100,0,000 BTU SYSTEM 300,000 +BTU ❑ 1 am exempt untler Section B. & P. C. for this ELECTRICAL $ $ BOILERS BTU MICROFILM $ PLAN CHECK $ TOTAL FEE $ MECHANICAL E AD - PLAN CHECK LESS E P E VANCE PC $ reason Date Owner - SYSTEM REPAIR, ALTERATION Thereby certifythat 1 have read this application and state that the above information Is correct. I agree to comply with all cif and count 9 PY Y e ordinances and state laws relating [e construction, and hereby authorize EXHAUST SYSTEM MULTIPLE representatives of this city to enter upon the above mentioned property for !!per n purposes. $igna[ureC� CMF 0865-46 White -Building; Canary -Applicant, Pink -Accounting; Goldenrod -Assessor CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit# Date Inspector 1. Temporary Electrical Service or Pole 43. Pool 8�Equipment Location ' ' ' 2. SoilPipe-Undrgrn - / -,j/ 44. Steel Reinforcement ' 3. Electrical Conduit Utility-Undrgrn 45. Forms 4. Electrical Conduit-Undrgrn 46. Electrical Bonding • -` - ^ 5. Steel ein orce 47. Rough Plumbing & Pressure Test - 6. Electrical LIFER Grn _ 48. APPROVAL TO COVER-GUNITE•�'- 7. Footings 49. Electrical Conduit-Undr rn 8. Foundation 50. Gas Pipe, ❑ Undr rn, Test 9. Water Pipe-Undrgrn 51. ^ Backwash Lines P-Trap, '0 ridr rn�• - 10. Structural Floor System 52. APPROVAL TO DECK - 11. Property Sewer Line & House Connection 53. Backwash & Rece for -Final 12. Street Sewer Connection 54. Heater & Vent -Final 13. Rough Plumbing - y/ - -- - - 14. Rough Electric -Conduit - 56. ` Electrical -Final. - 15. - -Rough Electric -Wiring 57. Solar System -Final 16. Rough Heating & Air Conditioning _ encing & Access Approval 17. Ducts in Structure APPROVED FOR PLASTERING 18. Ducts, Ventilating _ 60. POOL/SPA SYSTEMS FINAL - - - '- 19. Gas Pipe -Rough &Test 20. Roof Framing 21. Roof Sheathing- -� NOTES: , 22. Frame and Flashing 23. Insulation - 24. Lathing & Siding 251 Drywall Nailing 26. Plaster Brown Coat ' 27. Electrical Power Meter -Final 28. Final Electric ' 29. Final Heating & Air Conditioning 30. Final Gas Pipe -Test �• 31. Final Plumbing 32. Water Service -Final 33. Gas Service -Final - 34. Solar Domestic -Final - 35. Landscape Sprinkling System - 36. Sound Attenuation 37. Handicap Regulations - -- - 38. FINAL STRUCTURE & BUILDING - 39. Special Requirements Completed - 40. Electric Release to Edison " 41. Gas Release to Southern California Gas Co. 42. CERTIFICATE OF OCCUPANCY - No. Date - - - - Applicant to fill in all spaces except those within heavy border lines andsign all appropriate declarations. £I I I OF COSTA MESA CO $T UCTION PERMIT PERMIT NO. TRACT NO. LOT NO. UNIT NO. Project Address Applicant's Mailing Addres Owner's Name ,pp � � Phone Address S.) Arch/Eng. License No. Address Contractor's Nam Phone Address (mailing) Y IPC60�PP Al, �1 City License No 11 J LICENSED CONTRACTOR DECLARATION I hereby affirm that 1 am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 Of the Business and Professions Code, and my license is in ful f:�/aq/e� and effect License Clas Va /1. l i� toA Dale '7}y� S'g t/ WORKERS COMPENSATIONOLY DECLARATION I hereby affirm that I have a certificate of consent to self -insure or a certificate if Workers' Compensation. Insurance, or.a certified copy thereof (Section 3800, Lab. G) ' r {y/\ Policy No. i� tS lJ Company certified c, Py is is filedbwithrthencty B Date Applicant-,1✓'-^• 7, /Jt_��`/ EXEMPT(ON FROM WORKERS' COMPENSATION DECLARATION. (This section need not be completed If the permit is for one hundred ($100) or less). 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. Date Signature 'NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097 Civ. C.) Lender's Name Lender's Address OWNER BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional 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/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt -'herefrom and the basis for the alleged exemption. Any violation of Section '031.5 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 (Section .7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/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 com- pletion, the owner will have the burden of proving he/she did not build or'im- prove efor the purpose Of sale). ❑ I, as owner of the property, am exclusively contracting with licensed con- tractorsto construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor(s) license pursuant to the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me., ❑ I am exempt under Section B. & P. C. for this reason Date Owner _ I hereby certify that I have read this information is Correct. I agree to comp and state laws relating to building con sentatives of this city to enter upol inspection pur es Signature Drivers' License or SS # tion and state that the above all city and county ordinances i, and hereby authorize repre. bove-mentioned .property for / J ` Date ' /) TYPE OF CONSTRUCTION LJ NEW LJ ADD LJ ALTERATION ,LI REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P.# DESCRIPTION OF WORK/USE OF BLDG. S Main Buildi TYPE OF PERMIT GRADING ��I'FOU NDATION ❑STRUCTURAL T Front ❑ TENANT El ELECTRICAL VJ PLUMBING ❑ MECHANICAL B Rear ❑ OTHER A PROJECT DESCRIPTION SO. FT. OCCUPANCY C Right K Left CONSTRUCTION TYPE VALUATION $— $ ZONE GRADING CU.YDS. ACRES Ping. Ref. # Remarks: Planning Notes: 8177 8/06/85 Zone Accessory Building: Parking Req./Provided Z O N 1 N G R E O M T S TL Bar Sink Showers ELECTRICAL FEES Backflow, Preventer Service Sink Automatic Washer Transformer ❑ 15-50 KW ❑ 50+ KW Backflow Irrigation 9 Sewer Ca P Construction Pole Sub. ' Bathtubs Sewer Connection Cooking Unit . , Meter Cup to 100amps Clarifiers I Solar Collectors Dishwasher Meter ❑over 100 amps Dish wash Solar Piping Dryers ❑Gas ❑Electric Sub Panel Drinking Fountains Solar Tank Fan Motors ❑0-1HP 01 X,-8 Floor Drains Swimming Pool w/Spa F.A.U. Inc. Solar 09-15 HP 1116-15+ Floor Sinks Urinal Fixtures Microwave Gas Service Outlets Water Closet Device Boxes Pole Light Interceptors Water Heater Outlets Range Kitchen Sink - Water Service Switches Sign Lavatories Auto -Wash Garbage Disposal Standing Sections P—Trap Laundry Trays Generator 1:10-5 KW ❑5-15 KW Trash Compactor Roof Drains - Reinspection Fee Under Ground $15 Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Bit. ICBO+ Heating System & Ducting ❑ 0-100,000 BTU E3100,000 BT Reinspection Fee 1 $15 Issue Fee I $ 3 Reinspection Fea $15 Issue Fee $ 3 IANICAL FEES DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By Building Approved By Application Issued By Date Date Data-� Hood or Type ❑ Canopy Type I ❑ Refrigeration System 00-100,000 BTU ❑100,000 BTU BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL PLAN CHECK 25% SUMMARY OF FEES $ $ $ $ $ $ $ $ SMIP $ PERMIT ISSUANCE $ ENERGY P.C. $ GRADING $ MICROFILM 1 $ TOTAL FEE $ CT0-0 System Repair/Alteration Fire Dampers Registers — Issue Fee $ 3 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor CONSTRUCTION AND PLANNING - APPROVALS Permit# Date Inspector - POOL --SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or. Pole - ,- 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. - 53. Steel Reinforcement 3..,Electr1cai Conduit Utility-Undrgrnd. - 54. Forms - ' 4. Electrical Conduit=Undrgrnd. 55. Electrical Bonding - 5. Steel,Reinforcement, 56. Rough Plumbing & Pressure Test - 6. Electrical UFER Grnd'. 57. APPROVAL TO COVER-GUNITE 7: Footings _ 58. Electrical Conduit-Undrgrnd. -8. Foundation - 59. Gas Pipe, O Undrgrnd., Test 9. Water Pipe-Undrgrnd. - 60. Backwash Lines, P-Trap, ❑ Undrgrnd. 10. Structural Floor System - - - 61. APPROVAL TO DECK . 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final - 12. Sewer 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 APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑Gas ❑Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: g % �� zxrr cAeo c u 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test " 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final , 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation - 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison - - 1 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date _. APPLICATION FOR A BUILDING PERMIT 1 T _l Tract Block Lot BUILDING PERMIT NO. _ ,/aC7 1�Y Electrical Permit No. Building 41--Lo s., ` �, ! +11�� Address }'{�-Y]J`r -1/ Plumbing . Permit Plumping Cross 1('7/ Area C051<;j M�-5A Street l i�—�v -� Mechanical Permit No.� Owner M / C �5 C L5 IF-5 Typeof Project: El New ❑ Alter Yd'Adtlition Address S�M(_, Repair ❑ Convert ❑ Demo ❑ Occupancy arm. City Q r�— Zip Phone 64j,S /�❑ /^' ' losp. Area/ Architect/ Designer License No. Z e Sol. Pmt. No. Set cks P/L Front C/L St. Street Width Address t Yar Left Right Rea, City Zip Phone eve roi. LeftIg Engineer License No. Parking - eqp re rovl a overe Address City Zip Phone Sir uct Height No. of Storte No. of Family LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 Park Fees Required NY No C.T. Fee Receipt Zoning Approved By: Date (commencing with Section 7000 Of Division 3 of the Business and Professions Code nd my license is in full force and effe tl. Gry� License Ca, '— License Numbers Date — — ontrzcl, ✓ Address _ �` �'-� Misc. Proposed Use of Structure City and Zip Phone CONSTRUCTION LENDING AGENCY 1 hereby affirm that [here is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Occ. Class Tyoe Const. Code Year USE/ CCUPANCY SIZE SO. FT. Lender's Name Lender's Address 1. OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason: ❑ I, as owner of the property, or my employees with wages as their 2. sole compensation, will do the work, and the structure is not intended or offered for sale. ❑ I,. as owner of the property, am exclusively contracting with 3 4. licensed contractors to construct the project. ❑ I am exempt under Sec. , B8,PC for this reason Date_, Owner WORKERS' COMPENSATION DECLARATION Total Valuation Encroachment Permit Required ❑ V s ❑ No I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof. Policy No — Company ❑ Certified copy is hereby furnished. Cer ' uy1 c y is filed with Orange County,EMA, r2 / Dates Applicant�� J�-'A`S'P` IJ Grading Pmt. Required ❑ Yes ❑ No rading ml. No. Rough Grading Approved by: Date CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE rsection (This need not be completed if permit is for $100 or less). 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner s0 as to become subject to the Workers' Compensation Laws of California. PERMIT EES Data Applicant NOTICE TO APPLICANT: If, after making this Certificate of Structural $ Pla neck Is Exemption, you should become subject to the Workers' Compensation Elect viral f Special Invest. $ provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. plumbing $ I CERI IFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS Mechanical $ RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTH. ORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON TkLE ABOVE MENTIONED PROPERTY FOR INSPECTION PUP. POS- E Pre-Gratle Inspection E Sign ie of Applicant or Agent Dat Mt�`�L/A-old 223-1-7 Re Rec. No. . No. 6 Issue Permit 6 Print Applicant's/Agent's Name i All spaces within this box must be completed to process Plan Check BY: Issuance Approvetl: CMF 033546 (BU-28) rev. 6/80 HERINGTON, James JOB ADDRESS 4W Shac GENERAL CONTRACTOR AP No. 117-371-22 LOT DATE 4-8-63 BUILDING PERMIT NO. 19192 r-Bldr. VALUE $ 14,265.00 TRACT FIRE ZONE DESCRIPTION OF WORK Res.w att.aar. INSPECTIONS Signature DATE GROUP J&j TYPE V ZONE R-1 Soil , SUBCONTRACTOR PERMITS _ ISSUE. _ NUMBE,. Gas Q 3 a G3 DATE Water Rough Core. Refrig. 0 Air Cond. ❑` Rough Heating ��-' y�tv>-cow/-�(,r/, _ ��L _� 3 / /'-S Rough Plumbing �/t+✓ $-la •G �_�%'—_=�`f=/v___�/� Miscellaneous Prop. Swr. Line D9 House Con. PlIt. Swr. ❑ &rcpyLp�% s Sprinkling System Construction ole / Underground ❑ Power El Rough Wiring •( -t: 3 O r nc es orme !J Steelem .o _ Floor System Bond Beam ❑ Steel Reinforce ❑ Sheathing Frame and Flashing�- Lathing Out ©- {� Plaster, brown coat n Refrig. ❑ Air ond. ❑ Final Heating, Final Plumbing Fixtures, Final - Final Gas Test - - Electric Fixtures, Final 4.G - Building, Final _ OCCUPANCY FORM R114 - 5M — 7.91 1717G 19192 &STA)�ESA BUILDING -SAFETY DEPARTMENT P.O. 84X 317 COSTA MESA. CALIFORNIA For Applicant to Fill In Completely TYPE OR PRINT BUILDING ya ADDRE65 O AI r COSTA MESA, CALIFORN 1 CITY LOB /' /7C5f4. STATE TEL SIZE NO. Ofl OF LOT NOW EX STING BLOG. '.0 Y �4 / N�� SETBACK LINE FROM DESCRIPTION OF WORK ■ BUILDING SIZE �c EXTERIOR WALL i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM. PLY WITH ALL CITY ORDINANCES AND STAll[ LAWS R80 TING BUILDING CONSTR/I9ION. 1 AUTHORIZED AGENT MAR 2 6 1963 FINANCE DEP1. m OF COSTA MESA APPLICATION FOR PERMIT BUILDING For Office Use Only RECEIPT NO. RF M Y DATE RECEIVED I DATEiSSU[OI J ZONE NO.— II PLANSP I BUILDING USMONEW/"A: IIA M/if 'E: NO EAVE OVERHANG SHALL BE LESS THAN TO SIDE 9 REAR P. L. ES .OWED (U. S. C. REQUIREMENT' YARDSAPPROVED YAROSAPPROVED MAIN BUILDING ACCESSORY BUILDING tOM C/L STREET) VAR.# DATE C. U. P. APPR APPROVED 11 J////�I Imo? %/J SSG. FT. THE AMOUNT SHOWN UNDER VALU TION 1519OR THE S PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. O VALUATION t6� PERMIT FEE $ Vf i BX PLAN J E /IO TOTAL FEE $ //X W C. COSTA MESA BUILDING -SAFETY DEPARTMENT APPLICATION FOR STRUCTURAL PERMIT P.O.BOX1200 COSTA MESA. CALIFORNIA 92626 n For Applicant to Fill in Completely — Use Ink Only RECEIVED V PERM IQ p�2�Qj� 25. . • - ,BUILDING BUILDING fit' A ((� ADDRESS A.P. NO. Z' BUILDING ADORESS OWNER OR TENANT C L 1 r I M` CAr5 � UNIT ORN NO. SPACE MAILING C ./ ADDRESS % C TR.NO S LOT WA BLK. I L. CITY �� i-X NO. _ NEW ADD 4TER REPAIR MOVING DEMOLISH CONSTRUCTION LENDER BRANCH C OWNER %jl! ADDRESS VALUE USE E ARCHITECT TEL. OR ENGINEER N0. ZONE Igo TYPE GROUP -3 ADDRESS /, 1 ,��,I ,t .2 CONTRACTOR �/�P�'— �T \L'S1 Tg7��FQI�S BYPROV ED DATE ADDRE/S�S� /TN P'0-1 t-tM a -�/lC � rD�, /'�(�,t/ CITY 'i-3-1-�T�Ct'v- \ / l C-?& No. �� J 3J ^I ,(� / STATE 1 /Y�'�� LI C. NO. LT �O LIC. NO. /� UUU APPROVED SETBACKS SIZE (� 7 I OF LOT i d /� (3 �Q NO. OF BLDGS. NOW ON LOT ! (FROM C/L STRUT) $I FRONT T. USE OF �� 1��,�b EXISTING BLDG. K_+'� F Separate permits are required for electric, plumbing and heating work: r L. SIDE 17' FT. O r) REAR PLANNING ACTION USE OF BUILDING AND WORK T BE Nt PERFORM D ll_ �t S G.' tt -� �: DATE APPROVED 6�� APPROVED, L5 - 7_O A DATE 6 Gr �C nor 1 hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are in full force and effect, or I am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. Signature of ..j.� Permittee ��-�.�L.�/`-✓ '�\ Viv/ d SO. FT. r THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: VALUATION /7 176 $ {� 7 J/lnJ PERMIT FEE $ % Z• J PLAN CHECK E !Z TAX $or /-S (� Authorized Agent 0ate J ( iS TOTAL PAID $ We TL