HomeMy WebLinkAbout606 RHINE LN - Building Permits Cv-t/I-D/A-41"a Z
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COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Apslica r o Fi l-'n Co. . �r R tt��pprr,, v DATE cery
- _ _ y BUILDING . ._7C ' DATE ISSUED
ADDRESS f*In•••••H`°;;,. �a;ja_a I
PERMIT
OWNER HELTZER ENTERPRISES-BROOKVIEW A.P. NOR .-p(p( -03,(41)i7-03,(41)i7 - t :02
• BUILDING /
MAIL ADDRESS 740 N. La Brea Avenue ADDRE - •• . _ j--4
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- O CITY Los Angeles, CA 90038 NOL 937-2171 TRACT�j.^...�/ LOT BLOCK
Z Q CONSTRUCTION CaliforniaBank NEW ADD ALTER I REPAIR MOVING DEMOLISH
O a. m -LENDER UnitedCalifornia j r
• J D BRANCH Main Branch /X-
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ADDRESS S. Spring St. , L.A. 90054 �, LUE
-CO ARCHITECT
TEL USE4 :/e - A/ /Ce tt'/
UQ _OR ENGINEER Fields & Silverman N . 653-0160 FIRE �//
W m ADDRESS 113 N. San Vicente, Beverly Hills ZONE TYPE GROUP /p-'
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'APPROVED
LU Z _CONTRACTOR George J. Meltzer BY DATE
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. cc ADDRESS 740 N. La Brea Avenue
Lu w TEL. ��..QQN NO.OF 7 USE OF NEW LI C�)N'
Z F CITY Los Angeles, CA 90038 NO. 937-2171 1� -C� PLANS N5 v BUILDING T e„q2
ui V)EC LIC.NONO. 3144 LIC.NO. MAIE CITY N BUILDING APPROVED APPROVED
ACCE SORY BUILDING
SIZE NO.OF SLOGS. (FROM C//Lr STREET)
_OF LOT NOW ON LOT None FRONT !O FT. FT.
USE OF ..-) .4
_EXISTING BLDG. B.SIDE j FT.bet• FT,
I- SIZE OF NO.OF 2 2�.V� bit.
Q _NEW BLDG. ROOMS STORIES L.SIDE J �T.�Q,. FT.
EXTERIOR WALL_ 1 ROOFfaster COVERING Wood REAR 9 °'PT. FT.
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USE OF BUILDING AND WORK TO BE PERFORMED p DISTANCE BET. BET. MAIN&
O. Residen[ ial // MAIN BLDGS. ACCESS. BLDGS.p
Q ? I��/Ql /,�`J //], /.X/f•//,Wp/L� DATE
CURP.vOt ?E-73 /7 APPROVED O -2-0-7-2
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S y - —fY ROVED DATE
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k1 O •■1 hereby acknowledge that I have read this application and state a7 W-
,rh D that the above information is correct and agree to comply with
Iv cr all laws regulating building construction, and I shall not employ
V i- any person in violation of the workman's compensation laws of ) AX
CO the State of California. /ii:0 /12o a4 m
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z I hereby certify that I am properly licensed as a contractor under SQ. FT. o
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the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exempt from the provisions of the State of California Business VALUATION �/{TICC
• and Professions Cod inion 3,Chapter 9. �,/ PERMIT FEE $ 23s 5
-
- Signature of .. / /�/f }� m
Permittee . y'��2' $ //I J]9'��'✓ PLAN CHECK $ /7 /1 /- E
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Authorized Agent / u.
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• CITY OF CfOSTA MESA
T. FFR BUILDING DIVISION •
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4 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.costamesacgov
1
�. FOR INSPECTIONS CALL:(714)754-5626
. PERMIT NUMBER: BX13-00028
PERMIT TYPE B_MISC STATUS: ISSUED
APN: 93405095 DATE ISSUED: 02/11/2013
Zoning: , ISSUED BY: RMD
JOB ADDRESS: 606 RHINE LN CM- Suite/Unit:
Vicinity: ROOF MOUTNED . Primary Occ: Const Type: ??
SQ. FT: 0 , Valuation: $9,800.00 .
SCOPE OF WORK:INSTALLATION OF A 1.047 KW ROOF MOUNTED SOLAR PANEL SYSTEM WITH 1 INVERTER,
DISCONNECT AND MISC CONDUIT. ,
NOTE: FINAL APPROVAL OF PERMIT SHALL NOT BE GRANTED UNTIL ACCESS TODWELLING UNIT(S)IS PROVIDED FOR VERIFICATION
OF SMOKE AND CARBON MONOXIDE ALARMS BY THE CITY INSPECTOR. SEE ATTACHMENT W/INSPECTION CARD(Residential only)
OWNER: KOPEC, CONRAD J Address: 606 RHINE LN Unit:
City/State: COSTA MESA, CA - Zip Code:92626-3135 1 '-iN
Phone: 714-296-2144 - - "'k.
APPLICANT: ESCALON, LAURA l' • f - ., 'Address:- Unit: 11T i'1 \ ■
City/State: ' Zip Code:
Phone: 949-600-5005 - DATE:, 6�'
CONTRACTOR: UNLEASH SOLAR • License No.976594 OP-a-
Address: 4 MARCONIUnit: -
City/State: IRVINE, CA - _ ---- - ,• -
Zip Code: 92618 -• Phone 949-600-5005, Cell:
ARCHITECT: 'License No.
Phone - - .
ENGINEER: RICHARD J GODINA - < .License No. 33036
Phone
FEE SUMMARY -
Building Plan Check -$117.81- -
; .
Building Permit: $181.25 r
Electrical Permit: $62.10 '
SMIP Residential - ,$0.98- 7
SMIP Commercial -
Bldg Std Admin Fund . . $1.00 :
TOTAL FEES $241.46
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 -PER CMMC Sec. 13-279
Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibited all hours-Sundays and the following Federal Holidays:
New Years Day,Memorial Day, Independence Day, Labor Day,Thanksgiving Day and Christmas Day
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§ 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE U. INSPECTION TYPE DATE INTMALS CODE Ir INSPECTION TYPE DATE INTmALS
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
WORKERS'COMPGNSATIOf)DECLARATION: Owner ID verified by drivers license. ❑\Yes ❑No" t
I hereby affirm under penalty of perjury one of the following declarations: r Drivers License No. Expires:
❑ I have and will maintain a certificate of consent to self-Insure for workers Verification of Ownership by(type of document,i.e.-property tax bill or deed):
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Ti' I have and will maintain workers'compensation insurance, as required by
section 3700 of the Labor Code, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet in depth into which a
number are: person is required to descend,will be made in connection with work authorized
learner: { Gl • Q 1£ate --,. • by this permit,and that no building structure,scaffolding,falsework,or demolition
(this section need not be compie:•tithe permit is valued at one hundred dollars($too)or less.) or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp
� nn (� / ��72,Art 2,Sec.341,Title 8,California Administrative Code).
Policy Number: u CD") (013 � ` U�H
❑ As owner-builder, I will not employ anyone to do work which would
❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above, unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should
become subject to the workers' compensation provisions of Section 3700 of
the Labor e,I shall forthwith� comply with these provisions. Applicant's Signature Date
��• Q�t7°6L_/ ,-2 -// - /3 Division of Industrial Safety Permit Number:
Appli�nl's Sgnature r�'Date m HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes 0 No
($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND exceptions,that a Business Plan be filed with the Costa Mesa Fire Department
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: volume of 55 gallons, or 200 cubic feet of compressed gas at standard
I hereby affirm that I am licensed under provisions of Chapter 9(commencing temperature and pressure).
with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license/�is in full force and effect. C a registration form for acutely hazardous materials? 0 Yes ❑No
Lic:#--Y./. &s o1`I '" Class#. - ID (Section 25533 of the California Health and Safety Code, with some
'1 24 exceptions,requires registration with the Costa Mesa Fire Department by each
ri-`_ - L, C� r-f -/P — /3 business which at any one time has on hand a quantity of acutely hazardous
Contractor's Signature Date, - s 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
CONSTRUCTION LENDING AGENCY: pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? 0 Yes 0 No
Lender's Address: (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.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes ❑No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement
that he or she is licensed pursuant to the provisions of the Contractors License (Section 65850.2 of the California Government Code requires that the requested
Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business information be furnished on applications for non-residential building permits).
and Professions Code)or that he or she is exempt therefrom and the basis for 6. Will any part of the facility to be constructed under this permit be within
the alleged exemption. Any violation of Section 7031.5 by any applicant for a 1000 feet from the outer boundaries of a school? ❑Yes ❑No
permit subjects the applicant to a civil penalty of not more than five hundred (If"yes",the facility must meet the requirement of Sections 25534 and 42303
dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec. 7044,Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
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 8. (If-yes', attach certificate of compliance from the appropriate air pollution
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
city ordinances regarding Hazardous Materials and Emissions.
LICENSED CONTRACTORS to construct the project(Sec.7044, Business and
Professions Code:The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
❑ I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
the City of Costa Mesa to enter upon the above-described property for
Business and Professions Code for this reason: inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
Signature of Legal Owner(al Date
Signature Date ‘___AndJor.Authorized Applicant - r Date-._ -
)._-
3057-06(3/07)
oft ,‘,1,f,
unleash ,$- R
March 6, 2013
Re: Withdrawal of Permit Application for Permit##BX-13-00028/Customer Conrad Kopec
To whom it may concern:
Unleash Solar would like to withdraw the application for permit#BX-13-00028 for the proposed
photovoltaic system to be installed on Mr. Conrad Kopec's residence.
Please refund the unused portion of application fees to the address listed below.
If you require any further information,please do not hesitate to contact me.
Regards,
Dion Perdikoyiannis
CEO •
dion(1a,unleashsolar.com
(949)600-5005
4 Marconi Irvine, CA 92618
a-
'S� CITY OF COSTA MESA
4 - BUILDING DIVISION •
F tir• ,,,,, ; iI DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
•
PERMIT
J
AP
PO4-00495
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 606 RHINE LN Status: ISSUED
Suite No Applied: 07/19/2004
Issued: 07/19/200
Vicinity:
ISSUED BY:
Parcel Nunmber: 93405095 - -
Applicant: SZABO, KEVIN -
Address: 2737 S CRODDY -
STE D Phone: (714)241-1414
SANTA ANA,CA Zip: 92704 "
. � ,
Owner: KOPEC, CONRAD J -
Address 606 RHINE LN
Phone:
COSTA MESA,CA Zip: 92626-3135
Contractor: COAST ROOTER PLUMBING HTG &NCC
Address: 2737 S CRODDY 11 9 o cikzt
STE D P✓ , D Phone: (714)241-1414
' SANTA ANA,CA Zip: 92704 '
License: 529127
•
Arch / Eng : - - - --
Address:
• Phone:
Zip:
License: •
SCOPE OF PERMIT
CHANGE OUT WATER HEATER •
FEE SUMMARY ' ' '
AMT QTY - • AMT QTY " - AMT QTY
ISSUE FEE $23.50 Laundry Tub/Washer ' $0.00 0•1 - - Sump Pump - $0.00 0
Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0
Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer , .' $0.00 0
Bathtub $0.00 0 Pressure Regulator, $0.00 0 . Urinal $0.00 0
Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0' Vacuum"Brkr Bkflow(1-4) $0.00 0
Connect(Ice,Soda,etc) _ $0.00 0 Receptors $0.00 -0 Vacuum Brkr BkfloW(5+) $0.00 0
Dental Units . $0.00 0 ' Septic Tank $0.00 0 - Wash Basin/ .� $0.00 0
Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0
Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0
Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0
Drain, Roof $0.00 0 Shower $0.00 0 . "Water Heater/vent $12.30 1
Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0
Expansion Tank $0.00 0 Sink,commercial $0.00 ' 0 Water Re-pipe $0.00 0
Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
O I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: 5rt E Fu NJV Policy Number: I-7 108$S--2003
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
.171 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 Califo ia,and et t if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with those provisi n . 1
Applicant Signature: Date: I _ k 9.-O q
WARNING:FAILURE TO SECURE WOR ER COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES uP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDRION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR WOE,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.Lic.X 5,-9't 2'T 1'�/ `��, / Class M C-"'�L.
Contractor's Signature: / \�`� Date: 7—i q-D 4
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: Lender's Address:
•
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of 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 properly who builds or improves thereon,and who contracts for such project with a contractor(s)
. license pursuant to the Contractors License Laws.).
o I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,Celifomia Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No
(Section 25533 of the Califomia Health and Safety Code,with some exceptions.requires registration with the Costa Mesa Fire Department by each business which at any
one time has On hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aEermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 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? 0 Vas 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No
B (If'yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to Comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
.nn. ure Of Legal Owner(s) Date/
k 7 - i9-0 .7
- •• -nd/Or Authorized Applicant Date
CODE I INSPECTIOKTYPE DATE INTITIALS CODEX INSPECTION TYPE PALE MULE
1616 Fixed System Final Fire Prevention 206 Final Mechanical /��JO
1266 Pool Spa Final 208 Final Plumbing /L
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
I
203 Final Sign 222 Final Site i
204 Final Demolition 250 Final Building/Occupancy