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HomeMy WebLinkAbout3109 ROOSEVELT WAY - Building Permits CITY OF COSTA MESA 4111 BUILDING DIVISION e'f �, DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER � _111041 PERMIT y ""Manarc9 M00-00404 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 3109 ROOSEVELT WY Status: ISSUED Suite No Applied: 09/13/2000 Issued: 09/13/2000 Vicinity: ��j Parcel Number: 14169324 ISSUED BY: s„,.."1. Applicant: COOTER, LYLE Address: 1580-4 N BATAVIA Phone: (714)974-3004 ORANGE, CA Zip: 92867 Owner LEWIS, TIMOTHY J Address: 3109 ROOSEVELT WAY Phone: COSTA MESA,CA Zip: 92626 Contractor: TOTAL COMFORT SPECIALISTS Address: 1580-4 N BATAVIA Phone: (714)974-3004 ORANGE,CA Zip: 92867 License: 676628 Arch/Eng : Address: Phone: Zip: License: SCOPE OF PERMIT REPLACING EXISTING FAU(42,000)8 INSTALLING NEW AIR CONDITIONING SYSTEM(3 1/2 TON). 1 INST FAU< 100 K BTU, 1 REPAIR/ALT COOLING/HEAT, 1 3 TO 15 HP/500 K BTU. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion 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 $13.70 1 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 $0.00 0 Up to 3 hp/100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp/500 k BTU $27.15 1 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 Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $79.15 COMMFNTS/SPFCIAI rnNnITInNs_ 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(MO) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) ❑ 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: ✓J� / L=-O0 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 DOLLARE IS1o0,0001.IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I em licensed under provisions of tiapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class 4 Contractor's Signature: Date: `— • CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Cale). 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.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. 0 Yes ❑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 feel 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? 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? ❑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 end 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 appemit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LU No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 II 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 ell of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No 8 (If'lye5",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 un t final inspection. Signature Of Let:I Owner D. moo And/Or AutjS s ••plicant Date CODE I INSPECT10N TYPE PALE MAU LODEINSPECTiON TYPE r g6IE 1 1616 Fixed System Final Fire Prevention 206 Final Mechanical IC)^S©–� 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 pPCT•ADDRESS: 3109 ROOSEVELT WY UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO; B 068659 •`OWNER'SNAME: HORVAT, JERRY • ADDREss: HORVAT SHERI PERMIT NO; B 068659 PLAN CHECK NO; N GOV1 ; N SUPP ; N 3109 ROOSEVELT WAY COSTA MESA,CA 92626 CONSTRUCTION TYPE; V—N PERMIT TYPE: STR PURPOSE: ALT 714 ) 957-3084 ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION : SEE UNDER COMMENTS SQ FT; 4 , 500 ADDRESS: UNIT: CLAIM VALUE; 4 , 500 . 00 CALL—VALUE; 4, 500 , 00 GROUP OCC; R-3 /M-1 PERMITTEE: BURR ROOFING ( 714 ) 548-2965 ADDRESS: 711L0 DR * ****** ** ** F* *T * * * ** *** * ** **R ** ** * B**CM92627CA 92627 * ** * xr * r+ ****** * * * E4* **** * ** * * ** * *********** LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section ZONING R EQU IR EMEN TS 7000)of Division 3 01 the Business and Professions Code.and my license is in lull torte and effect. SETBACKS clTrLlc 1121 sTATELlc.: 3021577 ss. 39 EXP ; 09/94 �LS /� �j'/^_ MAIN BUILDING ACCESSORY BUILDING e signature:— FRNT; FT IN REAR: FT IN FRNT; FT IN REAR; FT IN (ERS'COMPENSATI NDECLARATION: (hereby affirm that Ihave acenilicate of consent to sell-insure oracertificate of Workers' LEFT; FT IN AGHT; FT IN LEFT; FT IN RGHT; FT IN ompensation of r e6o5a-sviheiL3c$py thereof(Section 3800.Lab.6.7/01 /9 5 POLICY No.: STATE FUND EXP.DATE: PARKING REQ: PROV: PARCEL ; 14169324 ZNE; REF NO; COMPANY: �[ PLANNING NOTES> El Certified copy is hereby furnished. 3 Certified copy is file with the cit �ilding Division. > 4 ******************************************************************************* Fr—Z�1`� Applicant DEVELOPMENT SERVICES REQUIREMENTS EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred($1170)or less). I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become ZONING APPROVED B Y subiect to the Workers'Compensation Laws of California. DATE Date: Signature: BUILDING APPROVED BY : DATE: NOTICE:lf.after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work forAPPLICATION ISSUED B Y; DATE; I 2.q ci*9- which this • LENDER:ermit is issued(Section 3097.Civ.C). SMOKE DETECTOR *************************************************************************** *** ADDRESS: y� /� �F LEGALIZATION;N F E E SUMMARY STRUCTURAL SEGMENT;Y REQUIRED BLDG PMT PLUMBING(PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING OWNER BUILDER DECLARATION: hereby affirm that I am exempt from the Contractors'State License Law tar the following reason PERMIT �}f 1�/L (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or �y r ' ` j,� E^�� . 50 repair any structure.prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed U� y IV' [�$MIP/NON—RES pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business PLAN //////''''''������ �wwr��••.... f and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by ISSUE FEEQ� any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500). BUILDING—DIV—> P E M I .�}r}i� P LAN—CHECK TOTAL PAID DUE I. as owner of the properly or my employees with wages as their sole compensation, wit do the work, and the TOTALS----> 72 , 50 0 . 00 —''--+ 0 . 00 72 , 50 72 . 50 , 00 ❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State 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 ar her own employees,provided that such improvements are not intended or offered for sale.If,however the budding or REVENUE DIVISION TOTALS--> COLLECTED ; 72 , 50 OVER/SHORT: , 00 improvement is sold within one year of completion,the owner will have the burden of proving he/she did not build or improve BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK for the purpose of sale). 72 , 00 . 50 I.as owner of the property.am exclusively contracting with licensed contractors to construct the project(Section 7044,Business ❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon *****,***.*.*************************.****.*****.***,***************,k***************** and who contracts for such projects with a contractors)license pursuant to the Contractors'State License Law).I am aware that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN ❑ I am exempt under Section: B.A P.C. for this reason: TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST Date: Owner: SFR 4500 REROOF BY VALUE RESIDENTIAL NOZONE 1 .00 4 , 500 , 00 I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and END OF FEES 25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction and hereby./horde representatives of this city to enter upon the above-mentioned property for inspection purposes. 01 00166819-00166320 TOT 72.50 1-2-9 -91 y 1641-46 white—Building;Green—Code Enforcement;Canary—Applicant;Pink—Revenue:Goldenrod—Assessor -Y CONSTRUCTION AND PLANNING POOL & SPA ' 1 APPROVALS Permit# Date Inspector APPROVALS Permit # Date InsRector 1, Temporary Electrical Service,or Pole 52. Pool & Equipment Location - 2. Soil Pipe Undrgrnd. , 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. ' . 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFERGrnd. 57. APPROVAL TO COVER-GUNITE 7. Footings ' 58. Electrical Conduit-Undrgrnd. 8. Foundation e' 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. . 60. Backwash Lines,P-Trap,0 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & Holtse;Connection c2. Backwash & Receptor•Final 12. Sewer Cap `Ca; Heater & Vent-Final r. 13. Roof Drains ' p4', 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 20. Rough Factory Fireplace 'APPROVAL`S ' Permit # - 21.,Ducts,in Structure . , 70. Underground Hydro 22. Ducts, Ventilating - ; 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe-Rough & Test , 72. Underground Flush . • 24: Roof FFraming - 731 Undergrnd.Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 8.419-‘71/ ,6t 74: Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat • 75. Ekry Chemical __ 27. Frame and Flashing76. Dry Standpipe , , 28. Lathing & Siding • -. 77. FIXED-SYSTEM FINAL 29. InsulationI 78: FIREf.REV. FINAL 30, Drywall Nailing I HEALTH DEPT. REQUIREMENT .- 31. Plaster Brown Coat 79: FINA JNSPECTION 32.-Electrical Power Meter-Final r 80. FO23D?CERTIFICATE ISSUED 33. Final Electric . Notes:.. - 34. Final Heating& Air Conditioning J. 35. Final Gas Pipe-Test , 36. Hood or Canopy 37. Final Factory Fireplace i 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 & BUILDINGt-/_e.j f GG�[ _ 48. FINAL PLANNING I l _T _ 49. Electric Release to Edison ' 50. Gas Release to Southern California Gas Co _ 51. CERTIFICATE OF OCCUPANCY No. Date C ft- CITY OF COSTA MESA 44x.9 BUILDING DIVISION et DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER f • ta.r�rwr`e t PERMIT E00-00918 lomM (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 3109 ROOSEVELT WY Status: ISSUED Suite No Applied: 09/13/2000 Vicinity: Issued: 09/13/2000 Parcel Nunmber: 14169324 Applicant: COOTER, LYLE ISSUED BY: - Address: 1580-4 N BATAVIA Phone: (714)974-3004 ORANGE, CA Zip: 92867 Owner: LEWIS, TIMOTHY J Address 3109 ROOSEVELT WAY Phone: COSTA MESA,CA Zip: 92626 Contractor: TOTAL COMFORT SPECIALISTS Address: 1580-4 N BATAVIA Phone: (714)974-3004 ORANGE,CA Zip: 92867 License: 676628 SCOPE OF PERMIT - REPLACING EXISTING FURNACE(42,000 BTU)8 INSTALLING NEW AIR CONDITIONING SYSTEM(3 1/2 TON). 1 MOTOR TO 10 HP. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 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 $0.00 0 up to 50 kva/kw - $0.00 0 Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 Switches $0.00 0 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 i . 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 1hp $0.00 , 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $12.30 1 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 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $35.80 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 2448-46(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have end will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. My workers�coomppensation Insurancelcarrier and policy number are: �7� Carrier: S '3 Go ) x / A '?OC) Policy Number: (`/-//� (CAN /i( efrQR(Sr7 (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify i in the fperformance, the ek for w this permitecis issued,I shall not kemploy s' amp person in any manner a as to becomef subject to the,I haf compensationh es ro siofomia,and agree if 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: _ �' 2 WARNING:FAILURE TO SECURE E S'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRINAI PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARE(5100000),IN ADDrTION TO THE .NST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in lull force and effect.Lic.# Class# Contractor's Signature: Date: i/; r ,.„tent,g CONSTRUCTION LENDING AGENCY: 9 ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not Intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of 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.). 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.-properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O 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). O As owner-builder. I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration lortn tort acutely hazardous materials? ❑Ves 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then 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 Cale been fully complied with? 0 Yes ❑No _ _—_o._ .___ ..._r modi...__t_ 5 Does or So the applicant or present a emen buting asoma requirer for the work which districtIs the nor agency?this application a ertnil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control or 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 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes,attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) /) fate a /t'f 3 2—0 a' (—) And/0 zed Applicant Date ;ODE I INSPECTION TYPE QdIE maw g9PL! INSPECTION TYPE PATE Ila 1616 FixedSystem Final Fire Prevention - 206 Final Mechanical 1266 PoollSpa 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 21348 FEE RECEIVED COSTA MESA BUILDING-SAFETY DEPARTMENT JAN 1 7 1904 P.O.BOX 2117 COSTA MESA,CALIFORNIA rr''FINANCE � DEPT. For Applicant to Fill In Completely APPLICA7101I��TIP P REiYSi r TYPE OR PRINT BUILDING C For Office Use Only ADDRESS 31c 1 lq`c_%eue..k \_,Clog RECEIPT NO. _ COSTA MESA. CALIFORNIA 2 VAl0 �\� 1 RECH VHD HY O T[p C IV8 ,/ OAT!ISSUED OWNER 1\414 \\01 q�a Vstcwn C � �� �T JHN 1 6 1964 MAIL r c n^ C 1 Lq, �\c r e_ ADDRESS FIRE . / ADDRESS I "1J`,NI y ADDRESS ✓ CITY \ TEL ZONE TYPE GROW fill ARCHITECT ur��\� ��,� 1 Tgl-���� APPROVED , OR :INEER 1� ``eV NQQS. CO i By DATE �/�t1 1 ZONING A ADDRESS Y 'Y\A Y\Q ; YY1 ''�� b ZON■ NO.or USE OF N/ CONTRACToRR )NAS P V Crwn t 4 vv-., . r I I PLANS -I''---'''7))Bu1L/DINS).LEGAL /�� ADDRESS `\SC � �C �"+1QV G DESCRIPTION-fa— NOTE: +474- 1 /„ //,/,1 % A CITY 1 i `hv\ 1 \\Y\ L C 1 \e.q A.P.NO. / J L� _ ` n•� NOTE: NO HAVE OVERHANG SHALL SE LESS THAN LIATE C.NO. 2'.J 0 11 NQ S 31--1,•] 9a. S0•TO SIDE a REAR P•L. EAVES OF LOT / S- X \Q tt.. I NO.OF BLOCS. XV. ALLOWED (U.B.C.REQUIREMENT) NOW ON LOT YARDS APPROVED YARDS APPROVED USE OF %../ / MAIN BUILDING ACCESSORY BUILDING EXISTING BLDG. J� (FROM C/L STREET) cSEETBACKOLFINE FROM ( CREAR YARD,/01FRONT 0FT. FT. SIDE YARDI LEFT S I RIGHT J R.SIDE cFr. {{' FT. DESCRIPTION OF WORK L.SIDE JFTFTT. FT. NE K ALTERATION II ADDITION REAR 2 FT. 1 DISTANCE BET. BET.MAIN a REPAIR MOVING DEMOLISH MAIN BLDGS. ACCESS.BLDGS. I�3 Li VAR. DATE BUILDING NO.OF SIZE ROOMS STORIES 1 C.U.P.# APPROVED EXTERIOR WALLROOF APPROVED,\q�.I I y -C 4 COVERING I COVERING BY 'R\ll DATE I USE OF BUILDING NDW KTOqE PERFORMED ��" \\ E 1e- c1tR)a.\VVC1 l.11C � /�7y80.FT. _ Z7o ACKNOW .- AT I -AVE R:• • THIS APPLICATION THE AMOUNT SHOW NDER VALUATION IS POR THE THA HH ABO ORRECT 0 AGREE TO COM. PURPOSE OP ESTA LISHING A PERMIT FEE ONLY. O O ITY OqO � TAT- LAWS q[GULATINOyALUATION �jfreim O +TqUCTION� $RE F PERMITFEEEi•ZED AGENT /5 ( /•y;//' fes/(/ TOTAL FEE $ 73^5e....;