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Home My WebLink About1649 SAMAR PL - Building Permits -5-13111%:` CITY OF COSTA MESA 4 BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER fl c, 1 PERMIT #* B03-01923 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 1649 SAMAR PL Status: ISSUED Suite: Applied: 11/05/2003 Vicinity: FIRST FLOOR MASTER BEDROOM Issued: 11/18/2003 Parcel Number: 13928128 Zoning: R1 R1 Applicant: FARTHING, SCOTT _ ISSUED BY: Address: ' _ Phone: 949-500-2870 Zip: Owner: ROMAINE,ROBERT F Address /1649 SAMAR‘PL - �/ - �/ ; �� Phone: - - / N� /.COSTA MESA,CAC.-- • - Zip: 92626 • - N\ , Contractor: 'FARTHING'DEVELOPMENT INC Address: 904 DOGWOOD =/. Phone: (949)500-2870 , COSTA.MESA,CA . Zip: - 92627 , . License: 560875 - Arch : Eng: Address: ' - - Address: , - i. Phone: Phone: , License: � License: - - SCOPE OF-PERMIT - -. ADD A 374 SQ.FT.SINGLE STORY,12-FOOT HIGH,MASTER:BEDROOM,AT LEFT FRONT OF THE HOUSE.RELOCATE ONE BATHROOM TO EXISTING MASTER BEDROOM AREA AND tbNVERT EXISTING BATHROOM TO CLOSET. EXISTING 4 BEDROOM/2 BATH RESIDENCE WILL REMAIN 4 BEDROOM/2 BATH - ' RESIDENCE. 40%OPEN SPACE REQUIRED;64%PROPOSED.: 4 - - " . 1FEE SUMMARY Plan Check: ',',;$450.29 - - Calc Valuation: $56,637.08 Permit: .$692.75 Claim Valuation:, ' $o.00 .SMIPRes:- ' 15:66 SMTP Corn: $0:00 \ Other. ; $0.00-, Inspection: ' $0.00N- . . \j / , , , , Total:-:vv$1,148.70 . PLANNING &ZONING SETBACKS - MAIN STRUCTURE Front 21-9 , . Rear 0-0 Left 7-0 Right ; 0-0 ACCESSORY Front 0-0 .Rear- 0-0 Left 0-0.- - —Right 0-0 / 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) WORKERS'.COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: r ❑ 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: Cartier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) 0 I certify that in the performance of the work for ich 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, agree I'- I •.uld become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. i o Applicant Signature: Date: /i/'O le3 WARNING:FAILURE TO SECURE WORKERS'COMPENSATI*Me e ERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES 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 ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licen eQ u deryrc of Chapter 9(commencing with Section 7000)of Division 3 of the Busingss an Professions Code,and my license Is in full force and effect.Lin.k h !2 COI Class q. a -C Contractors Signature: r e Date: J g//)3 i CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: _ _ _ Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom 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 soldwithin one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I.as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding.falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 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? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time 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 end Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future jading occupant require for the work which is the subject of this application appermit 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 LJ 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 ❑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. �9�� ar(s) ////0 And/Or Authonzed Applicant ate t CODE I INSPECTION TYPE QM INTtTUL$ CODEI INSPECTION TYPE RAIL MALI • 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 rr �1 204 Final Demolition - . .. 250 Final Building/Occupancy S-18-o4€ 2 N' • • ''4GEFREY DAVIS e 28 '405SEVILLE AVE. FAX( 949)7235 2941 __VW Z) 09- ALB DA,CA 92661 Phone(949)673-8082 Date SPECIAL INSPECTORS REPORT -Reinforced Concrete -Structural Steel (site) -Other EpoxY 8117BfZS -Post tensioned Concrete -Structural Steel (shop) -Reinforced Masonry -Fireproofing • Architect FAE HIIUG. D€V9DPMf 049-Us15-'15ZS Week Ending 1'24-0 Job Number AIDD`fr Engineer L.P. Lf LAVITr Report No. I InspectorDAV/S Page I of I Contractor a MIL DEVQDP'MT 94-11.64.57111.5— Building Permit No.B D3-- OI6123 Sub-Contractor WOAI Project Name RDM/i /V Lab receiving samples 1b44 SIM11-2PC CDS//-F ME-5A/CA Only one permit number per sheet.i Identify type of work, item and specific;area inspected (floor, gridline, etc ). Identify ,,, ti1all joints when inspecting welds and bolt connections, -Identif accepted and/or rejected work by item,and specific location. Record all�job;pems an robld DISCUSSIONS with Contractor, rchitec#, Engineer, etc. Record amount of matenal placed and samples taken. Write certification of work, referencing 1.g15p1icable code,'speclfications, approved plan and/or shop drawings., . SIM PSDN-SETZZTWO PAET CFVXY,BRTLA# U/S7D2D0 EXP. DATE `VOS 4 3.2 SIMPSON ALL-THD EEV I E1NE JJ APPROVED PLAN 4 WOLK SCHE U. TO RFDIV E TH/S_DIVE 11//77/ S/7E" S UPDZI/V TE71/DE 0 T. /MSPEL/±_P (4J UFAA/DRY flXES OU EXISTMIC,_ SOUTH L./V/NG. ROO Ail /V/A/G- ROOIV1 WA I • AMB/DVT 729.AP/Al 1-10LE5 5S°1-tiCOKET/ME 24*DUIS . ALLI/VaRKDDr1/E PEE RPPEDVM PLE/11 STRUCT. E717G2S EF. I. E3-412- / . SPCJf/L1177Di(/3 RFcti f4A, ¢ ®ci��• eZo• � sADDA " 0/fresnfs /I/nUDY— CALM—DSLY-- gip°F TIME IN TIME OUT REG. HOURS O.T. HOURS CERTIFICATION OF COMPLIANCE el:s OEM 1I;.30 M4 4- X I hereby certify that I have ins.•cted,to the• of my knowledge,all of the above reported work. Unless othe se noted,I . - •und this work to comply with the All inspection based on a minimum of 4 approved plans, -ec 'catio/ and ap • actions of the governing building hours. Inspections over 4 hours or codes. extending past noon,will be an 8 hour minimum. rT ! / IRVI S • • Inspector Project Representative /CL/10Eo SMVET STEEL IDSSIS3-SSS Certification Number and Agency ORRAI r CO.-- OS) p CITY OF COSTA MESA < � BUILDING DIVISION 'L. ,; DEVELOPMENT SERVICES DEPARTMENT PERMIT N BER , E4 . PERMIT eithift amm'� 03-00732 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 1649 SAMAR PL Status: ISSUED Suite No Applied: 11/05/2003 Issued: 11/18/2.03 Vicinity: MASTER BEDROOM/BATH - / a ISSUED BY: �� Parcel Nunmber: 13928128 - .. dr,/ Applicant: FARTHING,-SCOTT- , - 2 Address: 904 DOGWOOD .' - / ,. i Phone: (949)500-2870, /COSTA MESA,CA ' - , - Zip: 92627 / o,/, ,/ ' \ - Owner : ' ROMAINE, ROBERT F ' Address 1649 SAMAR PL• / 7' / Phone: ` ' ' \ COSTA MESA,CA Zip: 92626 - Contractor: FARTHING DEVELOPMENT INC -" Address:' ' 904 DOGWOOD ,- - v , - - - • - - - Phone: (949)500-2870 COSTA MESA,CA. _ Zip: . 92627 , License: 560875 - ,Arch / Eng:" , , i_ - - - _. _ - - - _ , - Address: . Phone: ------ -- - - Zip: , — - .. . • ' • , - License: - - - ' ;� SCOPE OF PERMIT_ ,', - ' HADD A 374 SQ. FT. SINGLE STORY MASTER BEDROOM::RELOCATE ONE BATHROOM TO EXISTING \ ' .• MASTER BEDROOM AREA AND CONVERT EXISTING BATHROOM TO CLOSET.EXISTING 4BEDROOM/2 / BATH RESIDENCE WILL REMAIN 4 BEDROOM/2 BATH RESIDENCE. \ . `. . REF:B03- 1923.PLUMBING TO INCLUDE: 1 BATHTUB, 1SHOWER, 1 WASH BASIN SET,-i'TOILET, , 1-WATER HEATER RELOCATE. ;�. FEE SUMMARY 2 . - ' '- "AMT - QTY • AMT QTYAMT QTY ISSUE FEE -v$23.50 " ' • Laundry Tub/Washer $0.00 0 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 "$9.80 - 1` 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 $9.80 1 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) $9.80 1 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 ii 244646(6/00) �� DECLARATIONS K__) 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 Cede,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 cNnpleted if the permit Is valued at one hundred dollars($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,and a. -: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. / /p Applicant Signature: //L /- Date: // / C� WARNING:FAILURE TO SECURE WORKERS'COMPENSAT 2:er;VERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOUJRE($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 licens u er Chapter 9(commencing with Section 7000)of Division 3 of the Business and P ofessions Code,and my license is in full force and effect.t ic.x 4 Class q n Contractor's Signature: ,/it/ Date: 7/&/ 61 3 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirrn 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: 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(5500).): ❑ 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 havethe 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: Dale: Owner ID verified by drivers license. ❑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: Dale: 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 feel 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 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 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 aaermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 01 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). 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 properly for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si ature Of Legal Owner(s) N fi Da ' ed Applicant ate ;ODE V INSPECTION TYPE • PAR tNTITIAL$ CODE INSPECTION TYPE, PATE EMU 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final - 208 Final Plumbing 5-1B-de 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 %"/ CITY OF COSTA MESA t BUILDING DIVISION Y %f.' :", I DEVELOPMENT SERVICES DEPARTMENT PERMIT N BER t. c %% PERMIT otmon mn"o (. ni_nnSR7 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 1649 SAMAR PL Status: ISSUED Suite No Applied: 11/05/2003 Issued: 11/18/2003 • Vicinity: MASTER BEDROOM/BATH Parcel Number: 13928128 ISSUED BY: / Applicant: FARTHING, SCOTT Address: 904 DOGWOOD Phone: (949)500-2870 COSTA MESA,CA Zip: 92627 • Owner: ROMAINE, ROBERT F Address: 1649 SAMAR PL Phone: COSTA MESA,CA Zip: 92626 Contractor FARTHING DEVELOPMENT INC Address: 904 DOGWOOD Phone: (949)500-2870 • COSTA MESA,CA Zip: 92627 • License:560875 SCOPE OF PERMIT ADD A 374 SQ. FT. SINGLE STORY MASTER BEDROOM, RELOCATE ONE BATHROOM TO EXISTING MASTER BEDROOMIAREA AND CONVERT EXISTING BATHROOM TO CLOSET.EXISTING 4 BEDROOM/2 BATH.RESIDENCE WILL REMAIN 4 BEDROOM/2 BATH RESIDENCE. MECHANICAL TO INCLUDE: 1 ALT/REPAIR OF AN EXISTING SYSTEM(DUCT WORK)AND 1 VENT FAN. 3/8/04-PERMIT SUPFL:TO INCLUDE 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 $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 $7.25 1 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 2446-46(6/00) 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 if the permit is valued at one hundred dollars($100)or less.) O 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 nd agree th 1 I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith rn comply with these provlslo L/ Applicant Signature: DateP `c`c/�7 WARNING:FAILURE TO SE RE WORKERS'COMPEN ION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE CnST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Busine s an fe ions pde as mm ycense is in full force and effect.Lic.A may) Class A tl� ` C,,t2 }$�7 Contractors Signature: �(u--� Date: 3/ 2 Q CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: _ 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 properly who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No 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,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? 0 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 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 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 a_aPermit 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 LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (if"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑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. ignature Of I Owner(s) Date 23/ 1 r7�u ' dApplicant v Date VOCE i fNSPECTION TYPE BLIE ' =ALE CODEC INSPECTION TYPE l7AIE If1I 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical 5.—lR-pc( 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 y`a ' CITY OF COSTA MESA iet @@ BUILDING DIVISION ). : DECLARATIONS L i `.y • 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 if 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, :•d agree that if I should become subject to the workers compensation provisions of Secti 3700 of he Labor Code,I shall forthwith comply with these provision:„.../ Applicant SignaturDate? //" %/_4/ � b C/ WARNING:FMWRE TO SECURE WORKERS'COMP 4.ga COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES 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 ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice0sedpids,p sio,rf Chapter 9(commencing with Section 7000)of Division 3 of the Businn an Do(ps5ic Code,and my license is in full ' force and effect.IJc.n 0 7(iPv ( Class u7 -T L Contractors Signature: ,/ Date: + // / $ 09 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.). • ❑ 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 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,Califomia 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 tiled 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 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 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 Califomia 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 ❑No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 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 feel from the outer boundaries of a school? 0 Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application,have all of the disclosures prescnbed by California Health and Safety Code Section 42303 been made? 0 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 property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. i i�t re=. - gel Owner(s) f///Vte And/Or:emir zed Applicant Date- • CODE I INSPECTION TYPE RALE INTmAMQ CODE! INSPECTION TYPE QA¢ KTUIWLE 1616 Fixed System Final Fire Prevention 206 Final Mechanical srl-1 cq-Oct RAI •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 _ _ ,-,0-sur CITY OF COSTA MESA o a. BUILDING DIVISION ) i •,,,� k1 DEVELOPMENT SERVICES DEPARTMENT P RMIT NUMBER � � PERMIT �E03-01037 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 1649 SAMAR PL Status: ISSUED Suite No Applied: 11/05/2003 Vicinity: FIRST FLOOR MASTER BEDROOM Issued: 11/18/2003 Parcel Nunmber: 13928128 Applicant: FARTHING, SCOTT - ISSUED BY: __;____d::S_ . Address: 904 DOGWOOD -_ , %, 1 Phone: (949)500-2870 COSTA MESA',:CA - Zip: 92627 - �\ - - , - Owner.- „'ROMAINE, ROBERT F'" � Address, 1649 SAMAR PN.' "- \ '� Phone: COSTA MESA,CA Zip: 92626 Contractor: -' FARTHING DEVELOPMENT INC - Address: : 904 DOGWOOD - ' .• - GPhone: (949)500-2870 " . . . COSTA MESA,CA c Zip: -92627 • License: 560875 - - i SCOPE OF-PERMIT - ADD A 374 SQ.FT.SINGLE STORY MASTER BEDROOM,RELOCATE ONE BATHROOM TO EXISTING MASTER BEDROOM AREAAND CONVERT EXISTING BATHROOM TO CLOSET. EXISTING 4 BEDROOM/2 BATH RESIDENCE WILL REMAIN 4 BEDROOM/2 BATH RESIDENCE. REF:B03-01923. ELECTRICAL TO INCLUDE:20 OUTLETS, 10 SWITCHES, 10 LIGHT FIXTURES, 1 " - RES APPLICANCE.(VENT FAN) " - - FEE SUMMARY ., ' - - „ • \ Quantity ‘. Quantity - ISSUE FEE ' ' � '."�",, $23.50Temp Dist System/Lighting Temp service"test $0.00 - �''Busway/100 ft $0.00 6' • - ' • Res.a/c package ;\ $0.00 ,.r•,? Standing Section $0.00i,,;,0 New Res.(1=2 units) 'xical$0.00 0 - Misc ElectrEquipment $0.00 " - 0 New Res(3+units) " " \•-$0.00 ; 0 Transformers up to 1 kva/k_w_- - ..$0.00 0 Pool/Spa '' ,,,�\ ,-, $0.00 ` 0 i '• up to 10 kva/kw $0.00 0 Lighting Fixts" 'C , '$11.00 10 up to 50 kva/kw $0.00 0 - • Recept Outlets \ / $22.00 - '- .20 ` up to 100 kva/kw $0.00 ', 0 . Switches `, $11-.00 - 10 over 100 kva/kw $0.00 TV�- 0 Non Res Appl A -$0.00 , 0 Low Voltage Equipment " $0.00 0 ' Res Appl N $4.75 - / , 1 - Low Volt Wiring System/Ckt'•' $0.00 /0 Service to 200a ''-c-- $0.00 ' 0 S ' Misc.Conduit ' , $0100 - ' 0' Service to 1000a N '' $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 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. IFOR INSPECTIONS CALL: (714)754-5626 11 • 244646(6/00) i 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,permil is issued. ❑ 1 have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Cede,for the performance of the work for which this permit is Issued. My workers'comperttation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if 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' Id become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. ,> Applicant Signature: Date: ////Op/I) WARNING:FAILURE TO SECU O RS'COMPENSATI ERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOUARE(5100.000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed der p of Chapter 9(commencing with Section 7000)of Division 3 of the Business and,P/21 ssions Code,and my license Is in full force and effect.Lic.N N n Class a' /3 /'71 Contractor's Signature: Date: // //X 0 3 CONSTRUCTION LENDING AGENCY: O 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).): O 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.). O I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the protect(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑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,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 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 Safely 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 0 No (Section 25533 of the California Health and Safely 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 0N (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 IRICalifornia 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 a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes I No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑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 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. *gnatur L al Owners) // // 5/nae And/Or A ed Applicant 1 ate ;ODE I INSPECTION TYPE QAIE $NTMAL$ CODE( INSPECTION TYPE RAIL PIT ALS • 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing TMJ 200 Final Re-Roof 210 Final Electrical 5_[g 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 PROJECT ADDRESS: 1649 SAMAR PL UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 062697 OWNER SD NAME:ROMAINE, SUSAN L A RA' SAMAR PL COSTA MESA,CA 92626 PERMIT NO; B 062697 PLAN CHECK NO; N GOVT: N SUPP: N ' CONSTRUCTION TYPE: 5—N PERMIT TYPE; STR PURPOSE: ALT A : ARCH/ENGINEER: REG.NO.: N : SQ JOB DESCRIPTION T/O,RESHEATH 1 /2"CDX & APPLY"TIMBERLINE" FT: 6, 380 ADDRESS: UNIT: PERMITTEE: CLAIM VALUE; 6, 380 . 00 CALC—VALUE: 6, 380. 00 GROUP OCC: R-3 /M-1 SANDKAMP ROOFING ( 714 ) 542-1742 ADDRESS: 124 N SULUVAN COMMENTS. GAF "TIMBERLINE" COMPOSITION ROOFING �-xye t SANTA ANA CA 92703 ********iE*******�r+Ex�E**�E�r***�r�r****�E�E�E;ESL****;r�Esr****+r�E�L�E�E**�E*** �r�r or * C 1 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTSgmfl 01 7000)of Division 3 of the Business and Professions Code.and my license is in full force and effect. SETBACK S �^' I��rD aTYUG:R41643 sTATEua362896 r ss:C_ �sfLJ ^ } "' - Date: `�- ,' `E"'S Signature. _ — MAIN BUILDING ACCESSORY BUILDI WORKERS'COMPENSATION DECLARATION: I hereby affirm that l have a certificate of sent to self-insure or a certificate of Workers' FRNT; FT IN REAR: FT IN FRNT: FT IN REAR: FT ING Compensation Insurance.or a certified copy thereof(Section 3800.Lab.C)_ LEFT; FT IN RGHT: FT IN LEFT; FT IN RGHT: FT IN . 'OLICYND.:1256300-93 EXP.DATE: 03/08/94 COMPANY:STATE FUND PARKING RE • PROV: PARCEL; 13928128 ZNE: REF NO: El Certified copy is hereby furnished. jJ Certified copy is filed wit a city Building Division. PLANNING N TES> >- Date: L->_2.--ta Applicant: ****************.*******************************************************.******** EXEMPTION FROM WORKERS'COMPENSATION OECLARATIO : (This section need not be co edit the permit is far one hundred($100)or less). D E V E ,'L O P M E N T SERVICES R E Q U I R E M E N__T. 'S I certify that in the performance of the work for which this permit is issued.I shall not toy any person in any manner so as to become r subject to the Workers'Compensation Laws of California. '`' 20NING APPROVED'BY DATE: Date: Signature: NOTICE:If,after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY : DATE: Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. >:, / CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED BY: � 1 � DATE: NJ� CS which this permit is issued(Section 3097,Civ.C). **.*.x.*************.M.*.**.*.****.*.)jjfff**iF 3F ****iE *1k iE ************lf**1E* . . . • . . ** LENDER: ******************************************* **** **********1E*************1F**** aDOREss: LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish.or PERMIT 90. 00 , 64 repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensedSMIP/NON—RES pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN .G' any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars($500). ISSUE FEE , j. I. as owner of the property or my employees with wages as their sole compensation, will do the work, and the BUILD INC D1 V > PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE I 0 structure is not intended or offered for sale(Section 7044.Business and Professional Code: The Contractors'State License Law TOTALS----> 90 . 64 0 . 00 0 . 00 90. 64 90 . 64 . 00. 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 completion.the owner will have the burden of proving he/she did not build or improve REVENUE DIVISION TOTALS--> COLLECTED: 90. 64 OVER/SHORT• 00 for the purpose of sate). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 90. 00 . 64 ❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon C. _.- and and who contracts for such protects with a contractor(s)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: FEE BREAKDOWN ❑ I am exempt under Section: B.&P.C. for this reason: TYPE QTY D E S C R I P T I O' N UNIT COST TOTAL COST Dale. Owner SFR 6380 REROOF BY VALUE RESIDENTIAL NOZONE 1 . 00 6, 380, 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 Duality 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 ,. hi ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned �1' 01 00141438-00141439 T'lET property for inspection purposes. 90.64 p� �� e DATE: 06/22/93 TIDE: 13:28 .-- Date: Co-a_O.-53 Signature: .7 Driver's License or Social Security Si 164146 white-Building:Green-Code Enforcement:Canary-Applicant:Pink-Revenue;Goldenrod-Assessor ' CONSTRUCTION AND PLANNING ,OL & SPA APPROVALS Permit# Date Inspector APPROVALS Permit # _ Date Inspector 1. Temporary Electrical Service or Pole , - 52..Pool & Equipment Location 2. Soil Pipe-Undrgrnd. - , 53. Steel Reinforcement ' 3. Electrical Conduit-Utility-Undrgrnd. . ; 54. Forms . 4. Electrical Conduit-Undrgrnd.. 55. Electrical Bonding 5. Steel Reinforcement. 56. Rough Plumbing & Pressure Test . ' 6. Electrical UF ER drnd. 57. APPROVAL TO COVER-GUNITE 7. Footings -- 58. Electrical Conduit-Undrgrnd. • 8. Foundation - 59. Gas Pipe, 0 Undrgrnd.,Test 9. Water Pipe-Undrgrnd. 1 60. Backwash Lines,P-Trap, 0 Undrgrnd. 10. Structural Floor System - 61. APPROVAL TO DECK ' . ' 11. Property Sewer Line & House'Connection . - 62. Backwash & Receptor-Final • ' 12. Sewer Cap . , 63. Heater & Vent-Final 13. Roof Drains - I 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 • 20. Rough FactocY Fireplace i •,. APPROVAE5: -Permit# , 21. Ducts, in.Structure. - • - - - 70. Underground Hydro 22. Ducts, Ventilating ` / - . ,71. Product.P,iping Odes 0Oi0 23. Gas Pipe-Rough & Test + - 72. Underground Flush 24.-Roof Framing - ` "i i - _ '73. 1`tdergrnd'.Storage Tank 0 Gas 0 Oil 25. Roof Sheathing.- ® 74. Overhead Hydro ro 26. T-Bar Ceiling (Structural) & Monocoat - . 75.,Dry Chemical , • 27.-frame and Flashing - , - 76. Dry Standpipe - 28. Lathing & Siding -,^ : " ` I '1 "I 77. FIXED SYSTEM FINAL' , - 29. Insulation LI I 78._FIRE PREY. FINAL 30. Drywall Nailing : . ; i- HEALTH. DEPT, REQUIREMENT .31. Plaster Brown Coat` . 1 - �.- 79. FINAL INSPECTION 32: Electrical Power Meter-Final . -- 11 f' 80. FOOD CERTIFICATE ISSUED 33.-;Final Electric I. - Notes: 07 ./47.3- 1 Y1 /VI _34,'FinalHeating.&ArConditioning. I '1 '1 . - . . 35.. Final Ga; Pipe-Tent ' - _ I - k1 ' I . 36. Hood or Canopy'. - - I - i 1 �• - 37. Final Factory Fireplace - ' - ' . 1 •,';;51'. • 38. Final Plumbing 1 I ' 7 ' 39. Water Service-Final. . 40. Gas Service-Final ' - I (- 41. Solar Domestic-Final -' - r •` 42. Backflow Preventers '' r1 ' - 43. Backflow Irrigation; ' _ - 44. Landscape Irrigation System _ t. • - - _ ." - ' • '45. Sound Attenuation _- - ' 46. Handicap Regulations - " . - ' _ 47. FINAL STRUCTUf3E;& BUILDING ?/t ',v - 48. FINAL PLANNING'• r i ' fJi j 49, Electric Release to Etlis on-_, 1l is' - .50. Gas Release to Southern'California Gas Co r 1 �,l• - - 51. CERTIFICATEOF;,O,CCUPANCY - No. • :Date 10934 • FEE RECEIVED Se} /f--,,2 '2-f COSTA MESA BUILDING-SAFETY DEPARTMENT DEPT. P.O.BOX 317 COSTA MESA. CALIFORNIA' • FINANCE CITY OF COSTA MESA . • FOR APPLICANT TO fill IN COMPLETELY APPLICATION FOR PERMIT TYPE OR PRINT BUILDING BUILDING 1649 Samar Place ADDRESS COSTA MESA, CALIFORNIA FOR OFF/CE USE ONLY ' RECEIPT NO. 19E{j411q'NO. OWNER Glenverde Homes, Inc. �c MAIL RECEIV O BY DAT RES'EIIV--EDD No ATE ISSUED ADDRESS BOX 65 /*NV V 2 3 1yb9 CITY Balboa Island,Calif. TNo0r3-4x220 ADDRESSf ARCHITECT LIC. COSTA MESA, CALIFORNIA OR ENGINEER NO. - FIRE ,., ` ADDRESS ZONE TYPE / GROUP Zeal CONTRACTOR x°iaCCO Corp. L C NO.STATE 98808 APPROVED DATE �^� ADDRESS Box .65, Balboa Island,Calif. ZONING �/LV�•/y/////�/ ,J,l LEGAL LOT ��}}1�ppq ZONE I NO.OF USE OF NEW '/ / yy—Q Y' 103 BLOCK TRACL481 PLANS 1R'_II BUILDING N /_A' DESCRIPTION NO. ('/\� • ' J APPROVED D I� F `�„ A.P.NO. BY 0. /y9 (J DATE i >0 SIZE 7000 I NO.OF BLOCS. O . YARDS W EVES {{{ OF LOT NOW ON LOT REQUIRED ALLOWED - USE OF (CENTER LINE ST.) EXISTING BLDG. FRONT . L 7-25FT. IN. SETBACK LINE FROMCENTER OF STREET Co53'"�REAR YARD 25 R.SIDE I ./J FT. IN. SIDE YARD I LEFT 6 RIGHT 13 L.SIDE G, FT. IN. DESCRIPTION OF WORK • REAR 1?FT. IN. NEW IX I ALTERATION (ADDITION • REPAIR I MOVING 1 DEMOLISH S ZIE DINGl6J.l7-/!xl16 NO.OF ROOMS 9 STORIES 1 EXTERIORWA411..LLL ROOF COVERING s'ACCO (COVERING shingle USE OF BUILDING AND WORK TO BE PERFORMED 1 �`?J rpsi Henri. . ({//j .{s� I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING PURPOSE OF ESTABLISHING A PERMIT FEE ONLY..CONST- ON. VALUATION SIGN U- O' ��IMI a �(l- -. I1 PERMIT FEE $� � PE-- ITT-E0111111r`r _ 111p �/ - -_- s/ /P9fo PLAN CHECK $/e149 AU D aGErvT ,\ TOTAL FEE $ L.5' 4/&