HomeMy WebLinkAbout1650 SAMAR PL - Building Permits r . 1 •
CITY OF COSTA MESA
(,�4-rn 114_ g ` •� BUILDING DIVISION
Fy ,) 77 FAIR DRIVE, COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.costamesacaMov,_ . •
:4 0014 i FOR INSPECTIONS CALL:(714)754-5626
4-bon, �' PERMIT NUMBER: B1.1-.00351_- .:
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PERMIT TYPE B_ROOF2 STATUS: . ISSUED " "" •
APN: 13928122 DATE ISSUED: 10/14/2011 _.
ISSUED BY: MDM
JOB ADDRESS: 1650 SAMAR PL.CM ' ' 'Suite/Unit:
Vicinity: _ i
Squares: 2400 __ . -• .. Valuation: • $7,500.00
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SCOPE OF WORK: 2,400 SQ FT RE-ROOF, REMOVE EXISTING SHINGLE ROOF, INSTALL 2 LAYERS..
-OF 15LB FELT, NEW
FLASHING AND 40 YR COMPOSITION SHINGLE
NOTE:RESIDENTIAL RE-ROOF: Final approval of permit shall not be granted until access to dwelling unit(s) is provided for
verification of the installation of'smoke and carbon monoxide alarms by the City Inspector. See Attachment w/Inspection Card
OWNER: REAL,M ATHENA . . Address:- 1650 SAMAR PL . • '"'Unit: -- '
PHONE: ' :. " City/State/Zip: COSTA MESA,CA -'••:` :.:4. .c.
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311-90'351
'APPLICANT: JOE SHULMAN - Address: •Un : . `
PHONE: 714-7997157 city/State/Zip:
CONTRACTOR: SHULMAN ROOFING • • License No. 870331 ' .'-- -------
Address: 7721 ETNACIUnit: PHONE: 714-799-7157 - '
City/State/Zip: HUNTINGTON BEACH,CA 92647 CELL: "1••::il'!1;
ARCHITECT: -. , License No. ' ' , PHONE:
ENGINEER: - License No. • - - PHONE:
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FEE SUMMARYv
Reroof Plan Check: $0.00 '';;ctr'ri for
. - -
._.. Ctian Card
Reroof Permit Fee: $153.25 -. . __ .
Reinspection Fee: $0.00 .
Bldg Std Admin Fund $1.00 - - . ''Uiu::
TOTAL FEES $154.25 11-i o n Ja 5 . _
HOURS FOR CONSTRUCTION ACTIVITY; EFFECTIVE 3/18/2010-PER CMMC Sec. 13-279
Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibitied all hours-Sundays and the following Federal holidays
New Years Day,Memorial Day, Independence Day, Labor Day,Thanksgiving Day and Christmas Day- ' , , ._. .. 1.i •
_.. -
. " . ••
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The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
:regulations. (Ord. No. 92-28, §1, 12-21-92)
.EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE I INSPECTION TYPE DATE INTRIAL$ CODES INSPECTION TYPE km INTITIAI$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
ItiI
1266 Pool Spa Final pp ;;--��aa 208 Final Plumbing """r' /`�
200 Final Re-Roof
fin__// 'l.(__ 210 Final Electrical 'P`'Itrrt• : .,rrl
201 Final Block/Retaining Wall 212 Final Fire Prevention r ini:- -
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site .. . • :
204 Final Demolition • 250 Final Building/Occupancy
:writ] Fe/1e'a1 noiidays�
WORKERS'COMPENSATION DECLARATION: - Owner ID verified by driver's license. ❑Yes U No
I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. f • r Expires:
0 I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed):
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
have and will maintain workers' compensation insurance, as required by
en 3700 of the Labor Code,for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
ate
permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a
number are: / I ( person is required to descend,will be made in connection with work authorized
1 / / I by this permit,and that no building structure,scaffolding,falsework,or demolition
Carrier: ^F rl��/�A//"'( ✓�✓Lm or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2,Gry
(This secron need not be completed A theehermit is valued at one hundred dollars(8100)or less.)
2,Art 2,Sec.341,Title 8,California Administrative Code).
Policy Number: l-7-1 l 0 ---2-0/0
❑ As owner-builder, I will not employ anyone to do work which would
❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above, unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should-
become subject to the workers' compensation provisions of Section 3700 of applicants Signature Data
the Labor Code,I shall forthwith comply with these provisions.
Division of Industrial Safety Permit Number:
Applicants Signature Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response t�elease or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 YesJ•,-"No
($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS (Section 25505 of the California Health and Safely Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST.AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant n d to file
my license is in full force and effect. p, a registration form for acutely hazardous materials? 0 Yes No
/� ' !
Lic.# • Class# C 1. (Section 25533 of the California Health and Safety Code, with some
�O! exceptions, requires registration with the Costa Mesa Fire Department by( each business which at any one time has on hand a quantity of acutely
--Pr entractes Signature Date hazardous materials equal to or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,CMI Code). prepare an RMPP (Risk Management revention Program for acutely
Lenders Name: hazardous materials)? 0 Yes No
(Section 25534 of the Califomia Health and Safety Code provides that the
Lenders Address: _ Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
Signature Date
4. If an RMPP is presently required, has Section 25534 of thefornia
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes Z No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management D_i5trict or from
construct, alter, improve, demolish, Or repair any structure, prior to its any other air pollution control district or agency? 0 Yes —❑ No
issuance,also requires the applicant for such permit to file a signed statement Section 65850.2 of the Califomia Govemment Code
that he or she is licensed pursuant to the provisions of the Contractors ( requiresbuildingnt thee requested
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the information be furnished on applications for non-residential permits).
Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this pe it be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes No
applicant for a permit subjects the applicant to a civil penalty of not more than (If'yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work whir the
offered for sale(Sec.7044, Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by alifomia
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
thereon,and who does such work himself or herself or through his or her own .8 (If"yes", attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree-to-comply with all state laws and
0 I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH city ordinances regardin s Materials and Emissions.
LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and /644,,22
Professions Code:The contractors License Law does not apply to an owner of � nature . Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
DI I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described 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) Date
signature • Date
305746(3I071 Andlor Authorized Applicant Date
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Prescriptive Certificate of Compliance: Residential CF-1R-ALT
Residential Alteratiohs , (Page 1 of 5)
Project Name: Zone ti t! of Stories
fi trim / Clint,A - r
General Information
Site Address: Enlhrcement Agency: Date: V/�t_/�e/'`/ /
7�si!
Building Type Ip�mgle Family ❑ Multi Family Circle the Front Orientation:N,E,S.W,or degrees / -
Project Type: 0 Alterations 0 Envelope 0 Fenestration ZBRtrof ❑ HVAC
Conditioned Floor Area(CFA): /360 Replacement or Change Out 0 Duct Replacement 0 Water Heater
NOTE: This_form is not to he used for New&v Constructed Buildings or Additions
Insulation Values For Opaque Surfaces(for Furring use the Mass and Furring Strips Construction table below)
Assembly Alteration
❑Opening of framed cavity alone-Alterations that involve the opening of the framed cavity of a wall, ceiling, or:floor must install the
mandatory minimum insulation value per§150 for the altered assembly.Fill in Columns A-C and enter mandatory insulation value in Column H.
❑Replacement of entire assembly-Replacement of at;entire wall, ceiling, orfloor assembly requires the installation of Component
Package-D insulation values in Table 151-C. Fill in Columns A-1
•
Opaque Surface Details For the furred portioned of Mass Walls see Furring Strips Construction Table below.
•A B C • I - D - N• • F - ' F G • H I ' V .J
Proposed Seen°" I Standard Values From JA4 Table
Framing Thickness, Framed Continuous JA4 Proposed
Tag/ Assembly Name Material Spacing, U- JA4 Table Cavity Insulation Assembly , Assembly
IDS or Type' and Size2 or Other3 •
factor" Numbers R-value •R-Value' Cell Values U-factory
•Note:For furred assemblies,accounting for Continuous Insulation R-value,see Page.44-3 and Equation 4-1. For calculating fiend walls use the Mass and
;Furring Construction table below.
1.For Tag/ID indicate the identification name that matches the building plans.
2.Indicate the Assembly Name or type:Roof/Ceiling, Walls,Floors,Slabs, Crawl Space,Doors and etc...Indicate the Frame type and Size:Far
Wood, Metal, Metal Buildings, Mass, enter 2x4, 2x6, or etc...see JA4 for other possible frame type assemblies.
3. Enter the thickness for mass in inches or Spacing between framing members enter; 16"or 24"OC;or Otherfar all other assembly description
such as Concrete Sandwich Panel,Spandrel Panel,Logs,Straw Bale Panel and etc....
4.Based on the Climate Zone;enter the Standard U-factor from Table 151-B, C or D for each different assembly Name or type.
5.Enter the Table number that closely resembles the proposed assembly.
6. Enter the R-value that is being installed in the wall cavity Or between the framing;otherwise, enter "0".
7. Enter the Continuous Insulation It-value for the proposed assembly; otherwise, enter "0".
8.Enter the row and column of the U-factor value based or Column F Table Number and enter the Assembly Ci-factor in Column J
9.The Proposed Assembly U-factor, Column J, must be equal to or less than the Standard U factor in Column E to comply.
Furring Strips Construction Table for Mass Walls Only
A B C I D l E F c } H I I J IC _ L M
Proposed Properties of Masonry and Concrete Added Interior or Exterior Insulation
Walls Front Reference in Furring Space from Reference
Joint Appendix Table 4.3.5,4.3.6.4.3.7 Joint Appendix Table 4.3.13
tcr
U 1 U
zLL
C , o v:
O
Assembly �. 7 `o F 2 F F•9 r,_ .2 °"v Fina!
Mass Name or JA4 Table 4 ` v o E Es 't m V g r Assembly
Thickness' Type: Number' < ^,.° w G LLC .', r _W K U-faet0ra'7 Comment
1
1 I I If
Registration Number: Registration Date/Time: HERS Provider:
2008 Residential Compliance Forms August 2009
t
[Prescriptive Certificate of Compliance: Residential CF-IR-ALT
IFr Residential Alterations + (Page 3 6-05) '
Project Name: Alt
t / Climate Zone #pf Stories
i
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t,tn 9 O
ROOFING PRODUCTS(COOL ROOFS)§151(fl12
When the area of exterior roof surface to be replaced exceeds more than 50%of rhe existing roof area,or more than 1,000 fr, whichever is
less,the new roofing area must meet the roofing product"Cool Roof' of§152(b)111i,152(6)1Hii, or 152(b)1Hiii.
Check applicable alternative or exception below if the roof alteration is exempt from the roofing product "Cool Roof"requirements.Note:If any
one of the alternatives or exception below is checked, the Aged Solar Reflectance and Thermal Emittance requirements for roofing products in
§1180 are not applicable.Do not fill table below.
0 of Roofs Not Required in Climate Zones 1-12, 14,and 16 with a Low Sloped. Less or 2:12 pitch.,
ool Roofs Not Required in Climate Zones I through 9 and 16 with a Steep-Sloped Roofs(pitch greater than 2:12)and product unit weight less
t an 51b/ft.
Alternatives to§152(b)1Hi and §152(b)Hii,Steep-slope roof(pitch>2:12)
O Insulation with a thermal resistance of at least 0.85 hr•ft2'°P/Btu or at least a 3/4 inch air-space is added to the roof deck
over an attic;or
❑ Existing ducts in the attic are insulated and sealed according to§151(010;or
_0 In climate zones 10, 12 and 13,with 1 ft'-of free ventilation area of attic ventilation for every 150 112 of attic floor area,and
where at least 30 percent of the free ventilation area is within 2 feet vertical distance of the roof ridge;or
❑ Building has at least R-30 ceiling insulation;or
❑ Building has radiant barrier in the attic meeting the requirements of§151(02;or
❑ Building has no ducts in the attic;or
❑ In climate zones 10, 11, 13 and 14,R-3 or greater roof deck insulation above vented attic.
Exception to§152(b)111iii,Low-slope roof(pitch<2:12)
O Building has no ducts in the attic. •
Other Exceptions
0 Roofing area covered by building integrated;photovoltaic panels and solar thermal panels are exempt from the below Cool Roof criteria.
1❑Roof constructions that have thermal mass over the roof membrane with at least 25 lb/ftis exempt from the below Cool Roof criteria.
' - Note:If no CRRC-1 label is available,this compliance method cannot be used,use the Performance Approach to show compliance,otherwise,
Check the applicable box below if Exempt from the Roofing Products"Cool Roof"Requirement:
Roof Slope Product Weight Product Aged Solar Thermal
CRRC Product ID Number _ < 2:12 >2:12 < 5Ib/ft2 > 51b/ft2 Type2 Reflectance3'4 Emittance SRis
❑ ❑ 0 0 ❑4
❑ ❑ ❑ 0 ❑4
❑ 0 0 0 04 .
O 0 0 0 ❑4 .
l
❑ 0 0 0 ❑4
1. The CRRC Product ID Number con be obtained from the Cool Roof Rating Council's Rated Product Directory at www.caotroofs.are/products/search.plm
2.Indicate the type of product is being used for the roof top,i.e.single-ply roof asphalt roof,metal roof etc.
3. If the Aged Reflectance is not available in.the Cool Roof Rating Council's Rated Product Directory then use the Initial Reflectance value from the sante
directory and use the equation(0.2+0.2(pmiria/—0.2)to obtain a calculated aged value. Where p is the Initial Solar Reflectance.
4.Check box ifthe Aged Reflectance is a calculated value using the equation above.
5. Calculate the SRI value by using the SRI- Worksheet at httn://www.enerey.ca.eov/tide24/mid enter the resulting value in the SRI Column above and attach atopy of
the SRI- Worksheet to the CF-IR.
To apply Liquid Field Applied Coatings,the coating must be applied across the entire roof surface and meet the dry mil thickness or coverage
i recommended bythe coatings manufacturer and meet minimumperformance requirements listed in 118 i 4. Select the applicable coating:
S 9 § O PP
I
0 Aluminum-Pigmented Asphalt Roof Coating 0 Cement-Based Roof Coating 0 Other
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I Registration Number: Registration Date/Time:: HERS Provider:
2008 Residential Compliance Forms • August 2009
_ r •
Prescriptive Certificate of Cumplianee: Residential CF-1 R-ALT
Residential Alterations (Page 5 of 5)
Project Name: Climate Zone jtI R of Stories
HERS VERIFICATION SUMMARY The enforcement agency should pay special attention to the HERS Measures specified in this
checklist below A completed and signed CF-41?Form.for all the measures specified shall be submitted to the building inspector before final
inspection.
Duel Sealing & Testing HERS verification is required for this measure.
❑ YES 0 NO YES:In Climate Zones 2 and 9-16,if more than 40 linear feet of new or replacement ducts are installed in unconditioned
space,the ducts are to be sealed pet §l52(b)IDii and the newly installed ducts are to be insulated per§;151(1)10.
❑ EXCEPTION: Existing duct systems that are extended,which are constructed,insulated or sealed with asbestos.
❑ YES 0 NO YES:In Climate Zones 2 and 9-16, if the existing space-conditioning system(HVAC equipment and ducting) is replaced,the
ducts are to he sealed per§152(b)1Di.
❑ YES 0 NO YES:In Climate Zones 2 and 9-16: if the existing HVAC equipment is replaced(including the replacement of the air handler,
outdoor condensing unit of a split system,cooling or heating coil,or the furnace heat exchanger)the ducts are to be
sealed per§152(b)IE.
O EXCEPTION:Duct systems that are documented to have been previously sealed confirmed through HERS
verification in accordance with procedures in the Reference Residential Appendix RA3.
- '- __ 0 'EXCEPTION:Duct systems with less than 40•linear feel in unconditioned space.. . . ---
❑ EXCEPTION: Existing duct systems constructed, insulated or sealed with asbestos. .
Refrigerant Charge- Split System HERS verification is required for this measure •
C YES 0 NO YES:In Climate Zones 2 and 8-15,when the existing HVAC equipment is replaced(including the replacement of the air
handler,outdoor condensing unit of a split system A/C or heat pump,cooling or heating coil, or the furnace heat
exchanger)a refrigerant charge measurement shall be verified per§152(b)1F.
Central Fan Integrated (CFI) Ventilation System and Fan Watt Draw
The ventilation requirements of§150(n)do not apply to existing residential homes.
Ducted Split Systems-Air Conditioners and Heat Pumps: Airflow HERS verification is required for this measure.
0 YES 0 NO YES:In Climate Zones 10 through 15,when the existing space-conditioning system(HVAC equipment and ducting)is
replaced.the airflow and fan watt draw shall he verified per§152(6)1 Ci to meet the requirements of§151(f)7B.
Documentation Author's Declaration Statement
• I certify that this Certificate of Compliance documentation is accurate and comp e.
Name:
5pe C / 1 Signature:
Ja�lr%tNh,9//r -
Company:
—^I 4 n Date.IVI Me //
Address: (r I ` t if Applicable❑ CEA o ❑ CEPE
( LSI V1 /� (Certification 4):
City/Stale/Zip: # Q/\� 6 I .// Phone:7jei y
Responsible Building Designer's`Declaration Statement
• 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the building design identified on
this Certificate of Compliance.
• 1 certify that the energy features and performance specifications for the building design identified all this Certificate of Compliance conform
to the requirements of Title 24,Parts I and 6 of the California Code of Regulations.
• The building design features identified on this Certificate of Compliance are consistent with the information provided to document this
building design on the other applicable compliance forms,worksheets,calculations,plans and specifications submitted to the enforcement
agency for approval with this building permit application.
Name: Signature:
Company: Date:
Address: . License:
City/State/Zip: Phone:
For assistance or questions regarding the Energy Standards, contact One Energy Hotline at: 1-800-772-3300.
Registration Humber: Registration Dare/Time: HERS Provider:
2005'Residential Compliance Farms August 2009
/4 c0 .5kM42 PL l`3JJ-O3C/
Prescriptive Certificate ofiCompliance: Residential CF-1R-ALT
Residential Alterations (Page 1 of 5)
Project Name: /� / anti, N I #of Stories
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1
General Information •
Site Address: Enforcement Agency: Date: 4,...H,,.;20/1
Building Type Single Family 0 Multi Family Circle the Front Orientation:N,E,S,W,or degrees
Conditioned Floor Area(CFA): )300Project Type: 0 Alterations 0 Envelope 0 Fenestration Pd-fnof 0 HVAC
Replacement or Change Out 0 Duct Replacement 0 Water Heater
NOTE: This'brut is not to be used fin Newly Constructed Buildings or Additions •
- Insolation Values For Opaque Sur/ices(for Furring use the Mass and Furring Strips Construction table below)
Assembly Alteration
❑Opening of framed cavity alone—Alterations that involve the opening of the framed cavity ofa wall, ceiling, or floor must install the
mandatory minimum insulation value per§150 for the altered assembly.Fill in Columns A—C and enter mandator,insulation value in Column H.
❑Replacement of entire assembly—Replacement of an entire wall,ceiling, or floor assembly requires the installation of Component
Package-D insulation values in Table 151-C Fill in Columns A—J.
Opaque Surface Details For the furred portioned of Mass Walls see Furring Strips Construction Table below.
A B C - D • E ' - F G • • H 1 - Q J
Proposed SeeNiue Standard Values From JA4 Table
Framing Thickness, Framed Continuous JA4 Proposed
Tag/ Assembly Name Material Spacing, U- JA4 Table Cavity Insulation Assembly Assembly
ID' or Type' and Size'- or Other' factor" Number' R-values R-Value' Cell Values U-factor9
•
j
' .Note:For furred assemblies,accounting for Continuous Insulation ft-value,see Page J44-3 and Equation 4-1. For calculating furred walls use the Mass and
i Furring Construction table below.
1.For Tag/ID indicate the identification name that matches the building plans.
2.Indicate the Assembly Name or type:Roof/Ceiling, Walls,Floors,Slabs, Crawl Space,Doors and etc...lndicate the Frame type and Size:For
Wood,Metal, Metal Buildings,Mass,enter 2x4, 2x6, or etc...see JA4 for other possible frame type assemblies.
3. Enter the thickness for mass in inches or Spacing between framing members enter; 16"or 24"OC; or Other for all other assembly description
such as Concrete Sandwich Panel,Spandrel Panel,Logs,Straw Bale Panel and etc.... .
4.Based on the Climate Zone;enter the Standard U factor from Table 151-B, C or D for each different assembly Name or type.
5.Enter the Table number that closely resembles the proposed assembly.
6. Enter the R-value that is being installed in the wall cavity or between the framing; otherwise, enter "0".
7. Enter the Continuous Insulation R-value jar the proposed assembly;otherwise, enter "0".
8.Enter the row and column of the U-factor value based on Column F Table Number and enter the Assembly U-factor in Column.l
9.The Proposed Assembly LI-factor, Column J, must be equal to or less than the Standard U-factor in Column E to comply.
Furring Strips Construction Table for Mass Walls Only
A I Ti C I D E F G B I J IS L M
Proposed Properties of Masonry and Concrete Added Interior or Exterior Insulation
Walls From Reference in Furring Space from Reference
Joint Appendix Table 4.3.5,4.3.6,4.3.7 Joint Appendix Table 4.3.13
• I � 1 , I v
w
` c�
Assembly F- I o = 5 o f,' . o;2 ,...2..,V v"'v Final
Muss Name of .IA4'table ”. b n 'v E n o E u O ? $ 7. Assembly
'thickness' Type' Number' 64. = ui c E �, ¢ w K U-factor" Comment
} ( I I • I I I
Registration Number: Registration Date/Time: HERS Provider:
2008 Residential Compliance Forms August 2009
Prescriptive Certificate of Compliance: Residential CF-IR-ALT
Residential Alterations (Page 3 615) '
Project Name: Ail l Climate loot #1)f Stories
ROOFING PRODUCTS(COOL ROOFS)§151(1)12 •
When the area of exterior roof surface to be replaced exceeds more than 50%of the existing roof area,or more than 1,000 ft', whichever is
less,the new roofing area crust meet the roofing product"Cool Roof'requirements of§152(b)1Hi, 152(b)1Hii, or 152(b)1Hiii.
Check applicable alternative or exception below if the roof alteration is exempt from the roofing product "Cool Roof requirements.Note:If any
one of the alternatives or exception below is checked, the Aged Solar Reflectance and Thermal Emittance requirements for roofing products in
§118(1 are not applicable.Do not fill table below.
❑ of Roofs Not Required in Climate Zones 1-12, 14,and 16 with a Low Sloped. Less or 2:12 pitch.
'ool Roofs Not Required in Climate Zones 1 through 9 and 16 with a Steep-Sloped Roofs(pitch greater than 2:12)and product unit weight less
t an 51b/&.
Alternatives to §152(b)llli and§152(b)Hii,Steep-slope roof(pitch>2:12)
❑ Insulation with a thermal resistance of at least 0.85 hrft2.°F/Btu or at least a 3/4 inch air-space is added to the roof deck
over an attic;or
❑ Existing ducts in the attic are insulated and sealed according to§151(010;or
❑ In climate zones 10, 12 and 13,with I (12 of free ventilation area of attic ventilation for every 150 ft=of attic floor area,and
where at least 30 percent of the free ventilation area is within 2 feet vertical distance of the roof ridge;or
❑ Building has at least R-30 ceiling insulation;or
❑ Building has radiant barrier in the attic meeting the requirements of§151(02;or
❑ Building has no ducts in the attic;or
❑ In climate zones 10, II, 13 and 14,R-3 or greater roof deck insulation above vented attic.
Exception to§152(b)1Hiii,Low-slope roof(pitch<2:12)
❑ Building has no ducts in the attic.
Other Exceptions •
0 Roofing area covered by building integrated;photovoltaic panels and solar thermal panels are exempt from the below Cool Roof criteria.
❑Roof constructions that have thermal mass over the roof membrane with at least 25 Ib/112 is exempt from the below Cool Roof criteria.
- Note:If no CRRC-t label is available,this compliance method cannot be used,use the Performance Approach to show compliance,otherwise, •
Check the applicable box below if Exempt from the Roofing Products"Cool Roof"Requirement:
Roof Slope Product Weight Product Aged Solar Thermal
CRRC Product ID Number' < 2:12 >2:12 < 51b/ft2 >— 51b/ft2_ Type2 Reflectance3'4 Emittance SRI
❑ ❑ ❑ ❑ ❑4
❑ ❑ 0 ❑ ❑4
❑ ❑
0 ❑ ❑4
❑ ❑ ❑ ❑ ❑4
❑ ❑ ❑ ❑
0
4_
1. The CRRC Product ID Number can be obtained from the Cool Roof Rating Council's Rated Product Directory at www,coolroo(s.orr/products/.seorch.plm
2.Indicate the type of product is being used for the roof top,i.e.single-ply roof asphalt roof metal roof etc.
3. If the Aged Reflectance is not available in.the Cool Roof Rating Council's Rated Product Directory then use the Initial Reflectance value from the sante
directory and use the equation(0.2+0.7(pt„prof—0.2)to obtain a calculated aged value. Where p is the Initial Solar Reflectance.
4.Check box if the Aged Reflectance is a calculated value using the equation above.
5.Calculate the SRI value by using the SRI-Worksheet at hitn://www.energyca.movitille241 and enter the resulting value in the SRI Column above and attach atopy of
the SRI- Worksheet to the CF-IR.
To apply Liquid Field Applied Coatings,the coating must be applied across the entire roof surface and meet the dry mil thickness or coverage
recommended by the coatings manufacturer and meet minimum performance requirements listed in§1180)4. Select the applicable coating:
❑ Aluminum-Pigmented Asphalt Roof Coating 0 Cement-Based Roof Coating 10 Other
+I�
Registration Number: Registration Date/Time: TIERS Provider:
2008 Residential Compliance Forms • August 2009
45
Iht The following shall comply with the?,010 California Residential Code
k�
.• requirements for re-roof: •
Batten' operated smoke•alarm shall be installed•at the following location(s) .CR.0 314 .
1- In each sleeping room
2- Outside each:separate sleeping area in the immediate vicinity of the bedroom(s).
3- On each additional story including basement(s) and habitable attics.
4- In dwelling(s) or dwelling units•with split levels and without an intervening door between the •
adjacent.levels, a smoke alarm•installedon the upper level shall suffice for the adjacent lower •
level-provided-that the•lower-level ds.less than one-full.story-.below the one full-story-below.. . . ..... . ..
the upper level.
Batten' operated carbommOnoxide alarm shall-he install atthe following location(sl CRC 315
1- Outside of each separate dwelling unit sleeping area in-the immediate vicinity of the
bedrooms)
2- On every level.of a dwelling unit including basements. -
Multiple purpose alarms.CRC 315.3. • .
Carbon monoxide.alarms combined with smoke alarms is allowed as per the manufacturers
lasting and the office of the State Fire Marshall for smoke alarms. •
Final approval of permit shall not-be granted until access of dwelllnq unit(s) is
provided.forverification-of-the;installation of smoke and .carbon•monox.ide .alarms
by the City inspector • -
0 - 1
CITY OF COSTA MESA
� ,@ BUILDING DIVISION
et:
d 1111 !" " 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.costamesaca.gov
4. FOR INSPECTIONS CALL:(714)754-5626
4c0"°'°"° PERMIT NUMBER: M11-00115
PERMIT TYPE MECH STATUS: ISSUED
APN: 13928122 DATE ISSUED: 10/20/2011
ISSUED BY: RMD
JOB ADDRESS: 1650 SAMAR PL CM -• Suite/Unit:--
Vicinity: '
SQ. FT: 0
SCOPE OF WORK: MECHANICAL PERMIT TO REPLACE AN EXISTING FAU LOCATED IN A CLOSET AND THE INSTALLATION
OF A NEW NC UNIT FOR SED. RE#:.E11-00235
OWNER: REAL, M ATHENA 'Address: 1650 SAMAR"PL Unit:
PHONE: City/State/Zip: COSTA MESA,CA .
APPLICANT: KOWERTZ;WILLIAMAddress: Unit:
•
PHONE: 949-795-4348 - • City/State/zZip:
CONTRACTOR: SOUTHERN CALIFORNIA ENERGY SERVICDES INC License No. 612389
Address: 17709 SAMPSON LANEUnit: - -.. - - PHONE: 714.969.8212 .
City/Slate: HUNTINGTON BEACH, CA - - ZipCode: 92647
CELL: ... .
•
MECHANICAL PERMIT FEE SUMMARY
MECH ITEM FEE: - $53.10 .
PLAN CHECK FEE: $0.00 - - -
INVESTIGATION FEE: - $0.00
REINSPECTION FEE: -. $0.00 - ,
TOTAL FEES: $53.10
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28, §1. 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE I, INSPECTION TYPE PATE IN1IALS CODES INSPECTION TYPE Dp DATE
_ INTRlALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical }C 1/• I f Do
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign _ 222 Final Site
' 204 Final Demolition 250 Final Building/Occupancy
WORKERS'COMPENSATION DECLARATION: Owner ID verified by driver's license. 0 Yes ❑No
I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires:
O I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed):
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
❑ I have and will maintain workers'compensation insurance, as required by DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet in depth into which a
number are: person is required to descend,will be made in connection with work authorized
—} i7. ,`ii( —C �� A t r-^t� `_ \/ by this permit,and that no building structure,scaffolding,false.work,or demolition
Caritas_ \�-1 1vY--'1�1� C- 7� or dismantlingthereof,will be more than thirty-six
(Tits not be completed dthe permit is valued n ASfW r2ss.) (36)feet high.(Chap.3.2,Grp
�"�-�'d�d`° �p'� 2,Art 2,Sec.341,Title 8,California Administrative Code).
PolicyNumb 7C") 1 \ l c3 —125
0 As owner-builder, I will not employ anyone to do work which would
❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California. and agree that if I should-
become subject to the workers'compensation provisions of Section 3700 of Applicant's Signature Date
the Labor Code,I shall forthwith o •ly with these provisions.
l \ \ Division of Industrial Safety Permit Number:
• gpplitanfrS' .w (^ ZO . I Oate=`+ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'ORCOMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes 0 No
($100,000), IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS (Section 25505 of the Califomia Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? 0 Yes 0 No
� �
LTA#�-- 1� Class AGI 0 C Z Section 25533 of the California Health and Safety Code, with some
_ exceptions, requires registration with the Costa Mesa Fire Department by
.� — F each business which at any one time has on hand a quantity of acutely
Contractors'.noatu e •at_e_Tho hazardous materials equal to or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
CONSTRUCTION LENDING AGENCY:' 2� I temperature and pressure).
O I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lenderfs Name: hazardous materials)? ❑Yes 0 No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes ❑No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the Califomia Government Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be fumished on applications for non-residential building permits).
License Law(Chapter 9 (commencing with Section 7000)of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec. 7044, Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
thereon,and who does such work himself or herself or through his or her own
8. (If'yes',attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
❑ 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 Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
❑ am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
Signalu e• Leg)1• er(s) Date �
Signature Date � '` { 0 . ( j) ' `1
305746(3/07)
AndlprArerr.Ap•
kto S. S1=.rvn a_ et
/r PLANNING
t=w2._1z APPROVAL
City of Costa Mesa Planning Div.
Subject to Building Division Regs.
Any Revision must be approved.
RequiredPri r to Building Final:
DYES ;Alb Zoning Inspection
DYES [atao Traffic/Park Fees
By: //l2fr Date: /0/2011
Need ACC
Mit friritrd
. .
•
ss
3a 3S'
'Set=v__
Lk 1-0u COQ LAI—) I '.
an'
V
CITY OF COSTA MESA
04111 tits BUILDING DIVISION
>a ,1 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.costamesaca.qov
%1 _._
.. in'. FOR INSPECTIONS CALL:(714)754-5626
°"'°"gt`°'�" PERMIT NUMBER: E11-00235
PERMIT TYPE ELEC STATUS: ISSUED
APN: 13928122 DATE ISSUED: 10/20/2011
ISSUED BY: RMD
JOB ADDRESS: 1650 SAMAR PL CM Suite/Unit:
Vicinity:
SCOPE OF WORK: ELECTRICAL FOR PERMT FOR THE INSTALLATION OF NEW NC UNIT LOCATED AT REAR YARD. REF#M11-00115
OWNER: . REAL, M ATHENA:': Address 1650 SAMAR'PL Unit:
PHONE: - -City/State/Zip: - COSTA MESA, CA
APPLICANT: KOWERTZ;WILLIAM . . Address: Unit: - - " "
PHONE: 949.7954348 , - City/State/zZip:
CONTRACTOR: SOUTHERN CALIFORNIA ENERGY SERVICDES INC License No. 612389
Address: 17709 SAMPSON LANEUnit: - PHONE: 714-969-8212 I
City/State: HUNTINGTON BEACH, CA - ZipCode: 92647 '
CELL: - - - -
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $78.00 '
Reinspection Fee . $0.00. ' . .
TOTAL FEES $78.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, §1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE P_ INSPECTION Mt &E INTITIALS CODE# INSPECTION TYPE DATE INTIIIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing i 200 Final Re-Roof 210 Final Electrical $ D/(' p' /I CV)
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
WORKERS'COMPENSATION DECLARATION: Owner ID verified by driver's license. ❑Yes 0 No
I hereby affirm under penalty of perjury one of the following declarations: • Driver's License No. Expires:
❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed):
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
O I have and will maintain workers'compensation insurance, as required by
section 3700 of the Labor Code, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
permit is issued. My workers' compensation Insurance carrier and policy I hereby certify that no excavation five(5)or more feet in depth into which a
number are: ` person is required to descend,will be made in connection with work authorized
Carrier: ��� A C.“-- —��� SU��h�.-� hl�.thLi permit,aqd fha no building structure,scaffolding,falsework,or demolition
Carrier:
need notm mmyeted Athe g-lhar✓a ill be more than thirty-six(36)feet high.(Chap.3.2,Grp
ti—fnus `^ perrnrt is valued at one hundred dollars($100)ortess.) 2,Art 2,Sec.341,Title 8,California Administrative Code).
Poli�cy.Number: H n, 0 8 0
❑ As owner-builder, I will not employ anyone to do work which would
❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above, unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should•
become subject to the workers' compensation provisions of Section 3700 of Applicant's Signature Date
the L.tor Code,I shall forth 'th comply with these provisions.
USDivision of Industrial Safety Permit Number
Npatt Ston.ur: DM
\0 •2-0 \ 1 ° HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions. that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
LICENSED CONTRACTORS DECLARATION: 500 pounds. or a volume of 55 gallons, or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full^force�Caannd effect.QC. I O j C Z�registration form for acutely hazardous materials? ❑Yes ❑ No
Lic.# `ZJ V 1 LYassJt_ (Section 25533 of the California Health and Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by
• ! _,� f each business which at any one time has on hand a quantity of acutely
Contra signature-- Ueta hazardous materials equal to or greater than a weight of 500 pounds, or a
^1
CONSTRUCTION LENDING AGENCY: ( • 1 volume of 55 gallons, or 200 cubic feet of compressed gas at standard
C ZO 1 temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,CMI Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lenders Name: hazardous materials)? 0 Yes 0 No
(Section 25534 of the California Health and Safety Code provides that the
Lenders Address: Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes ❑ No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the Califomia Govemment Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits).
License Law(Chapter 9 (commencing with Section 7000)of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and 6. WII any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If-yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK. and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec.7044, Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
thereon,and who does such work himself or herself or through his or her own
8. (If"yes". attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
❑
properly, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions.I, as owner of the
LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and
Professions Code: The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
ID I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
7 1
Signature of legal• ens) t O Date CD +
Signature Date • " ��„% • l
3057-46(3/07) ;. -.. ., Data
•
ITISCITY OF COSTA MESA ,
4
BUILDING DIVISION
). %
DECLARATIONS O 0
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:
Cartier. Policy Number:
(This ion need not be completed if the permit is valued at one hundred dollars($100)or less.)
I-r--rm.,.e that i t erformance 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'
,..---compensatio taw of California,and agree that if I should become subject to the workers'compensation provisions of Sect' n 3700 of the Labor Code,I shall forthwith
comply with this visions.^ / c o ' /
rApplicant Signature: V' (��.-v(,/ `'Ditterr-'--- (°
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(S100.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F 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 full
force and effect.Lic.# Class it
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 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 end 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
-subje the applicant to a civil penalty of not more than five hundred dollars($500).): •
1-- 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 a- pt unde .,.c. _/ ar Business and Professions Code for this reason:
Slgnature:t. ' , T 00� ----r-- t Date`:�_`Z�f/l/°to
OWn ITB D 7.rified by driver's license. ❑Yes 0 No Driver'sLicense No. `1-"" Expires:0.40 fi
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? ❑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 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 ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this as plication 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? 0 Yes 0 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:
CERTIFI TE 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 Tee to comply with all state laws and cityordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-des ' propertxffoorr ins q, atom pu agr °t to occupy or allow occupancy of any building authorized by this pe it until final inspection.
Sign�lure Of,Legal Owner(s), � ;_p l.- Date
And/Or Authorized Applicant Date
CODE E INSPECTION TYPE DAR al , CODE? INSPECTION TYPE, PAM INTTAV&
1618 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof - 210 Final Electrical
201 Final Block/Retaining Wall . 212 Final Fire Prevention .
202 . 'Final Factory Fire Place 220 Final Planning Approval '
203 Final Sign 222 Final Site
204 Final Demolition _ 250 'Final Building/Occupancy
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MANDATORY MEASURES SUMMARY: RESIDENTIAL (Page2of2) MF-IR
Space Conditioning,Water Heating and Plumbing System Measures: (continued) Enforce-
NA, Designer ment
5.Insulation must he protected from damage.including that due to sunlight,moisture,equipment maintenance,and wind. 0 0 0
6. Insulation for chilled water piping and refrigerant suction pipineincludes a vapor retardant oris enclosed entirely in ❑ ❑ ❑
conditioned space.
7.Solar water-heating systems/collectors are certified by the Solar Rating and Certification Corpnmrrnn 0 0 0
• §150(m): Ducts and Fans
I.All ducts and plenums installed,sealed and insulated to meet the requirement of the CMC Sections 601, 602,603.604,605
and Standard 6-5;supply-air and return-air ducts and plenums are insulated to a minimum installed level ofR-12 or enclosed
entirely in conditioned space.Openings shall be sealed with mastic,tape or other duct-closure system that meets the applicable 0 0 0
requirements of UL 181.UL 181A.or UL 181B or aerosol sealant that meets the requirements of UL 723. If mastic or tape is
used to seal openings greater than 1/4 inch.the combination of mastic and either mesh or tape shall be used.
2.Building cavities.support platforms for air handlers,and plenums defined or constructed with materials other than
sealed sheet metal.duct board or flexible duct shall not be used for conveying conditioned air. Building cavities and ❑
support platforms may contain ducts.Ducts installed in cavities and support platforms shall not be compressed to cause
reductions in the cross-sectional area of the ducts.
3.Joints and seams of duct systems and their components shall not be scaled with cloth back rubber adhesive duct tapes ❑ El ❑
unless such tape is used in combination with mastic and draw bands.
4.Eehaust ran systems have back draft or automatic dampers. 0 0 0
5.Gravity ventilating systems serving conditioned space have either automatic or readily accessible,manually operated ❑ ❑ ❑
dampers.
6.Protection of Insulation.Insulation shall be protected from damage,including that due to sunlight,moisture,equipment
maintenance,and wind.Cellular foam insulation shall be protected as above or painted with a coating that is water 0 0 0
retardant and provides shielding from solar radiation that can cause degradation of the material.
7.Flexible ducts cannot have porous inner cores. 0 ❑ 0
*I 14: Pool and Spa Heating Systems and Equipment.
I.A thermal efficiency that complies with the Appliance Efficiency Regulations.on-otTswitch mounted outside of the ❑ ❑ ❑
heater.weatherproof operatine instructions.no electric resistance heating and no pilot light
2.System is installed with:
a.at least 36"of pipe between filter and heater for future solar heating 0 ❑ ❑
f
b.cover for outdoor pools or outdoor spas 0 0 0
3.Pool system has directional inlets and a circulation pump time switch. 0 0 0
§115: Gas tired fan-type central furnaces.pool heaters.spa heaters or household cooking appliances have no continuously ❑ ❑ ❑
burning pilot light. (Exception:Non-electrical cooking appliances with pilot<150 Btu/hr)
§1 18(i): Cool Roof material meets specified criteria 0 0 0
Residential Lighting Measures:
fl §150(k)I:HIGH EFFICACY LUMINAIRES OTHER THAN OUTDOOR HID'contain only high efficacy lamps as
outlined in Table 150-C,and do not contain a medium screw base socket(E24/E2o) Ballast for lamps 13 warts or greater 0 ® 0
are electronic and have an output frequency no less than 20 kHz
§I50(k)1:HIGH EFFICACY LUMINAIRES-OUTDOOR HID:contain only high efficacy lamps as outlined to Table ❑/ Ed ❑
I30-C. luminaire has factory installed HID ballast
§I50(k)2: Permanently installed luminaires in kitchens shall be high efficacy luminaires.Up to 50 percent of the wanage.as
determined in§130 Ic).of permanently installed luminaires in kitchens may be in luminaires that are not high efficacy ❑ r-.( ❑
luminaires,provided that these luminaires are controlled by switches separate from those controlling the high efficacy lig
luminaires.
§150(k)3:Permanently installed luminaires in bathrooms,garages.laundry rooms utility rooms shall be high efficacy
luminaires.OR are controlled by an occupant sensors)certified to comply with Section 119(d)that does not tum on 0 [f( 0
automatically or have an always on option.
§I sockµ-.Permanently installed luminaires located other than in kitchens.bathrooms,garages.laundry rooms.and utility
rooms shall be high efficacy luminaires(except closets less than 701-01:OR are controlled by a dimmer switch OR are
20
IL�J�/ ❑
controlled by an occupant sensor that complies with Section 119(d)that does not tum on automatically or have an always
on option
§1301k/5:Luminaires that are recessed into insulated ceilings are approved for zero clearance insulation cover(IC)and areL7
� ❑
certified airtight to ASTM E283 and labeled as air tieht(AT)to less than 2.0 CFM at 75 Pascals.
§I AAP):Luminaires providing outdoor lighting and permanently mounted to a residential building or to other buildings on
tIe same lot shall be high efficacy luminaires(not including lighting around swimming pools/water features or other ❑ IJ,-.f ❑
Article 680 locations)OR are controlled by occupant sensors with integral photo control certified to comply with Section
1191d).
*130007:Lighting for parking lots for 8 or more vehicles shall have lighting that complies with Sec. 130. 132.and 147. ❑ ❑
Liehtine for parking garages for S or more vehicles shall have lighting that complies with Sec. 130. 131.and 146.
*1500:181 Permanently installed lighting in the enclosed.non-dwelling spaces of low-rise residential buildings with four or / ❑ O
role dwelling units shall be high efficacy luminaires OR are controlled by occupant sensotts)certified to comply with
Section 119(d)
AResidential Compliance Forms April 2005
RESIDENTIAL KITCHEN LIGHTING WORKSHEET WS-5R
Project Title Date
At least 50%of the total rated wattage of permanently installed luminaires in the kitchen must be in luminaires that are high
efficacy luminaires as defined in Table 150-C. Luminaires that are not high efficacy must be switched separately.
Kitchen Lighting Schedule. Provide the following information for all luminaires to be installed in kitchens.
Luminaire Type High Efficacy? Watts x Quantity = High Efficacy Watts or Other Watts
c9'x/i/6n WAiic Yes/ No❑ SD x 4- _ -7,0 0 or
(/ND'en---CA+t I WC Yes d No o 10* x 'I S = I 5Th or
Yes❑ No❑ x = or
Yeso No o x = or
Yes❑ No❑ x = or
Total: A: 72(P) B:
COMPLIES IFA >_R Yeso Noo
Rules for Determining Residential Kitchen Luminaire Wattage
Screw Base Sockets§130(c)1
(Not containing permanently installed ballasts) The maximum relamping rated wattage of the luminaire, as listed on a
permanent factory-installed label (luminaire wattage is not based on type or wattage of lamp that is used).
Permanently or Remotely Installed Ballasts§130(c)2
The operating input wattage of the rated lamp/ballast combination based on values published in manufacturer's catalogs
based on independent testing lab reports.
Line Voltage Track Lighting (90 through 480 volts)§130(c) 3
1. Volt-ampere(VA)rating of the branch circuit(s)feeding the tracks; or
2. The higher of
• The wattage(or VA)rating of an approved integral current limiter controlling the track system or
• 15 watts per linear foot of the track;or
3. The higher of
• 45 W per linear foot of the track or
• The total wattage of all of the luminaires included in the system.
Low Voltage Track Lighting(less than 90 volts)§130(c)4
Rated wattage of the transformer feeding the system, as shown on a permanent factory-installed label
Other Lighting §1313(c) 5
(Lighting systems that are not addressed in§130(c) 1-4)The maximum rated wattage, or operating input wattage of the
system, listed on a permanent factory installed label, or published in manufacturer's catalogs, based on independent testing
lab reports.
EXAMPLE
RESIDENTIAL KITCHEN LIGHTING WORKSHEET WS-5R
Project Title Date
Kitchen Lighting Schedule- Provide the following information for all luminaires to be installed in kitchens.
High Efficacy
Luminaire Type (y/n) Watts x Quantity = High Efficacy Watts or Other Watts
CFL-I Yes 26 x 5 _ _ 130 or
MR-I6 No 55 x 2 = or /10
x = Of
X = Or
x = or
Total: A: 130 B: 110
COMPLIES IFA >_B Yes El No CI
Residential Compliance Forms April 2005
„cLli.. CITY OF COSTA MESA
; ,� �\ BUILDING DIVISION
toF ( ^ � ) DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
4 In • PERMIT M06-00650
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT •
Job Address: 1650 SAMAR PL Status: ISSUED
Suite No Applied: 10/13/2006
• Issued: 10/13/2006
Vicinity: KITCHEN,BATHROOM,DINING AREA AND LIVIN
Parcel Number 13928122
ISSUED BY:
Applicant: REAL, M ATHENA - 7 '
Address: 1650 SAMAR PLS ' ;--<- - .- i -
',2 _.'Phone: 714-914-5020
COSTA.MESA;CA' , '., Zip: _ 92626-3628 ,
Owner /REALM ATHENA __ _ - ,
Address/!1650 SAMAR PL - -
� ', �� j Phone: 714-914-5020
-�� 1/COSTA MESA;CA Zip: 92626-3628 .. . . ,
/i; ` v kjz 7-7& I•
Contractor: OWNER-BUILDER ,
..Address:. 4%,� ,t, ,, y,,�„ ia. 43r .�1*,,it*,
/ i ' /c !�. Phone:- 2�grt_tk'i.. n
Zip: A ,
_ y,.,' License:000000 " .
�: ' "SCOPE OF PERMIT
-:MECHANICAL PERMIT FOR AN INTERIOR LIVING ROOM,KITCHEN,DINING ROOM AND MASTER
iBATHROOM.REMODEL.-
' N. ' REF#:B06-01741/
WORK TO INCLUDE:1 REPAIR/ALT COOLING/HEAT,1 HOOD W/MECH EXHAUST AND 2 VENT
‘ - FAN/SINGLEDUCTi- -;-;7 ,"`' '."r _ ,
•
FEE SUMMARY -
-
Quantity ," _ Quantity
ISSUE`FEE $23.50--' / - "' -- , Repair/Alt Absorbtion Unit $0.00 0
Inst FAU<100 k BTU _' $0.000 - - - -----7--- --- Repair/Alt Refrigeration-Unit $0.00 0
Inst'FAU,>100 k'BTU` . $0.00 0 - ' - Ventillation System .' $0.00 0
Repair/Alt Cooling/Heal $13.70 1 Evaporative Cooler - $0.00 - 0
!net/.RepRecess.WallHtr $0.00 0 Commercial Incinerator $0.00 0
Refrig-Sys<100 k BTO (, $0.00 0 Domestic Incinerator $0.00 0
Refrig-Sys>100 k BTU ' $0.00 0 Compressors/Absorption Systems
Gas Piping J $0.00 0 rt'''`_. .'-'-Up to 3 hp/100 k BTU $0.00 0
Factory,Fireplace' \:\\‘, $0.00 0 ;Tr r
5'-, '- . - 3 To.15 hp/500 k BTU . $0.00 - 0
Hood w/Mech Exhaust, $10.65 1 . ..-- • 15To301hp/1,000k BTU $0.00 ' 0
VAV Box -H-. ,��_$0 00 0 . 30 To 50 hp 1,750 k BTU $0.00 0
Vent Fan/Single Duct \ ;$1450 '2 ;H' - c- _ Over50 hp/Over 1,750 BTU $0.00 0
Appliance '. - �' Nv$000 ' 0 - Boilers
Fire DampersV, A N.�/ $0,60.,:'.s.;,0 'Up to 3 hp , $0.00 0
Smoke Dampers\ v.A,v /C/f /� _$000- '� - ' _ ,v, 3To 15 hp . ,' / - $0.00 0
Inst or Relocate Appl Vent U/ / $0 00 0 `�`-, 15 to 30 hp $0.00 0
Air Handlers< 10000cfm--\, ,,� $0,00`1 0 - - ' . ^30 to 50 hp - ' $0.00 0
Air Handlers> 10000cfm, -,L;.,, '7 $0.00? -/0- \ ... ' - _ _
Over 50 hp $0.00 0
Floor Furnace N, ""--.. $0.00'%,0• ', Other Mechanical Fee
Floor or Suspend Heater -•x'$0.00`-0 ' ' .I ' - Investigation Fee $0.00
' -- .Plan Check Fee - $0.00
\C,1'7:..._ _ .‘„
Reinspection Fee $0.00
- - '/ TOTAL CALCULATED FEES $62.35
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�andr
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of thissppermit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
•
DECLARATIONS , .
WORKERS'COMPENSATION DECLARATION: '
I hereby affirm under penalty of perjury one of the following declarations: ,
❑ 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'compensation Insurance carter and policy number are:
Carder: Policy Number:.
(This action need not be completed it the permit is valued at one hundred dollars($100)or less.)
certify that t 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 ws 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
C �,compty with the provisto O
-AppllWnfSignatur 1 • / Date: :-._...• /�/I
WARNINGr FAILURE RE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(VOODOO).IN ADOmON 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
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.# Class It
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 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).):
'-51,•!...71,es 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.
, .-J7044,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
pi. I,
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.).
pI,as owner of the properly,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)
lice pursuant to the Contractors License Laws.).
❑ I am e t under : Business and Professions Code for this reason: -
Signatura: ICS p 1GDa.ter it CV f 9/7 b
Owner ID v tied by drivers license. Yea ❑No Driver's Ltc`ens1NO.- Y Expires: OR 19
Verification of Ownership by(type of document,i.e.-property tax bill or deed):�rP� �"• -+ ?
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 ❑No
(Section 25505 of the California Health and Safely 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;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 a plication aermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency'? U Yes 0 No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No
(If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application.have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 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 perjurythe information given above is correct. agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
C CATS OF COMPLIANCE AND Aaws an city ordinances
OF ENTRY: I certify under penalty of perjurythat I have read this application and slate 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- cribed pr rty for' spec'on ugry ea I free not to occupy or allow occupancy of any building authorized by this permiyuntil final inspection.
74
OyF,�`'"l `o 3/o
Signature OLL.egal Owner(s) Date"'—]
And/Or Authorized Applicant Date /
CODE I INSPECTION TYPE 128TE INTITIAL$ CODEI INSPECTION TYPE -1 nil.1616 Fixed System Final Fire Prevention _ 206 Final Mechanical .43: t - 1 ,- . _
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Root 210 Final Electrical
201 Final Block)Retaining Wall 212 Final Fire Prevention
202 'Final Factory Fire Place - ' 220 Final Planning Approval
+Y
203 Final Sign 222 Final Site '
204 Final Demolition 250 Final Building/Occupancy '
•
' CITY OF COSTA MESA
BUILDING DIVISION
°q.-" 1- DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
%. 1 r' r�" 1
4. Irgli PERMIT
P06-00843
%3/47RanD\I
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesasa.usfriLuMBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
•
Job Address: 1650' SAMAR PL Status: ISSUED
Suite No Applied: 10/13/2006
Issued: 10/13/2006
Vicinity: KITCHEN,BATHROOM, DINING ARE AND LIVING
•
Parcel Nunmber: 13928122
Applicant: REAL, M ATHENA ISSUED BY: /!►I
Address: 1650 SAMAR PL - - -
' :/ <. ,Phone: 714-914-5020 .
COSTA MESA,CA„/i'�_ ' Zip: 92626-3628
,7�� •- mea 0,
'
Owner REAL;M-ATHENA:. �v
Address /1650 SAMAR'PL " „.-' _ - - - - _ - - '"4110:‘;
.,, s ws• .;�;+
,.F \, ' � ': Phone: 714-914-5020 p"
J r/COSTA MESA,.CA Zip: 92626-3628 f)*$
Contractor: OWNER=BUILDER ,, ,
Address 72:'-2,/7 ",:
/ / • . i,.; % Phone:' -
1.i /1,2'l: Z
' Zip. r
License: 000000
' , //, • " SCOPE OF PERMIT
PLUMBING PERMIT FOR AN INTERIOR LIVING ROOM,KITCHEN,DINING ROOM AND MASTER
- r 'BATHROOM REMODEL.
,_,
REF#:B06-01741 ---•-•
/
✓ I i'' - -WORK TO INCLUDE:1;BATHTUB,1`CONNECT(ICE,SODA),,1 DISHWASHER,1 LANDSCAPE
, " - IRRIGATION, 1 SHOWER;1.KITCHEN SINK,1'WASH BASIN,1 WATER CLOSET AND 1 WATER
_ REPIPE. `\
�,
--.� =°"-,r--FEE'SUMMARY
' t:,, :' AMT QTY.r.:;,_ _. - _ .- -AMT' C Y AMT . QTY
ISSUE FEE- t ' \ $23.50 Laundry Tub/Washer •$0.00 0 Sump Pump $0.00 0
Backflow irrigation $0.00 0 Landscape Irrigation ,$14.80 1 Swimming Pool $0.00 0
Backflow Preventer ` $0.00 0 ' P-Trap - $0.00 0 Trap Primer . - $0.00 0
Bathtub). C , \ \\`\ . $9.80 11 Pressure Regulator - $0.00 0 Urinal $0.00 0
\
Clarifier System i• \., .,$0.00 0. Process Piping(per,1
��^0 ft).. $0.00 0 Vacuum Brkr Bkflow(1-0) $0.00 0
Connect(Ice,Seda,etc) \s9.80 1 Receptors_, n-, �--,.$0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0
Dental'Units `- ' "$0.00 0 Septic Tank-c "t• ,'-$0:00 0 Wash Basin $9.80 1
Dishwasher`-, • $9.867 1' Sewer Cap for Demo " $0 00 . .0 Wash Basin Set $0.00 0
Drain,Floor'-r $0.00'-- 0, = ""
Sewer Connect $0.00 0 . Waste and Vent System $0.00 0
� J=
Drain,Rainwater moo`x\`N 0, -Sewer Private Line . $0.00 0 Water Closet(Toilet) $9.80 1
Drain,Roof \\_'\ /$0.00 A 0 '\�, Shower' '2 $9.80 1 "Water Heater/vent $0.00 0
Drinking Fountain-..SA C/$0.001 0' �,\'Sink,bartt.\' , ' ' $0.00 0 . r Water,Piping(Inst or Rep.) $0.00 0
Expansion Tank\A\ 1$0.00"-7 0 �..� `Sink,commercial si' " $000 _0..- Water Re-pipe • / $9.80 1
Gas Earthquake Valved \$0.00 7 0^., -Sink;Floors;_',A - $0.00`" -0"- ' Water Service ' $0.00 0
Gas(1-4 outlets) N„,":,•::;$0.06:::-),0/' ),--,, Sink;kitchen ' _. $9.80 1 - Water Softener $0.00 0
Gas(Over 4 outlets) ;`x$0.00, \0`. r, 'Sink,.service/mop - ._ $0.00 0 - OTHER $0.00
Gas Repipe '$0.00...-_ 0 - ,Spa-(private). . . $0.00 0 VIOLATION $0.00
Gas Service $0.00. 0. .,. Spa(public) ,. '$0.00 0 PLAN CHECK $0.00
Interceptors(Grease,Oil) $0.00 ------,PC.,;:-..,_ - '-._J _ , '- REINSPECTION $0.00 0
Interceptors(Sand Auto) $0.00 0"---...<:.:.-5,-;,--,:_., .'�- - ' , -' '"
- " . TOTAL CALCULATED FEES: $116.70
C/lMMCIJTC /CDFCIAI Cl1Mr11TIflPJC
•
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
2446-48(e/W) '
DECLARATIONS C .1 (. )
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:
Cartier: Policy Number:
—((Thiis/s section need not be completed if the permit is valued at one hundred dollars($100)or less.) -
I�I certity,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 otCalifomia,and agree that if I should become subject to the workers'compensation provisions of Seciipn 3700 of the Labor Code,I shall forthwith
4-comply-wim,thees Pro>Visions. 2.Z O l r�. / D1//�Y)/O
5.
Appli Signature: (JJ YY�) �/h'rl-ti"A/ 0 xti(.e i Date:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER-TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND 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 licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Llc.# Class#
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code),
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that 1 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 end 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
iv ls'rthe 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.).
cr" I.as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractors)
license pursuant to the Contractors License Laws.).
❑ I am ex t under Business and Professions Code for this reason: /
Sigrmture v 1• tDate:�-/Di * if
-=1- l` App I Owner ID verified by driver's license. 0Yes No DriversLloehse Na,-No. ! - Expires:-M70
Verification of Ownership by(type of document,i.e.-property tax bill or deed): 1.--r-4-et--
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 Califomia Health and Safety Code been fully complied with? 0 Yes 0 No
e. _
5 Does or So the tcAir or present or future building occupant at other for the work which isi the subject of this a pliestion a0p Nnit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? �Yes LJ No
(Section 65850.2 of the Califomia Govemment Code requires that the requested information be fumished 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'lyes",the facility must meet the requirement at 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:
CERTIATE 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 gree 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-de ribed property for i pection p ses.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
lf
Signature Of Cegal'Owner(s)t. Date
And/Or Authorized Applicant Date
•
CODED INSPECTION TYPE PATE tNTfTULS CODED INSPECTION TYPE RAM =all f
1616 Fixed System Final Fire Prevention 206 Final Mechanical - • ' Lf to�
1266 Pool Spa Final - . 208 Final Plumbing - "\ lwA
200 Final Re-Roof 210 Final Electrical .
201 Final BlocldRetaining Wall • • .212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolitionh. - ' 250 Final Building/Occupancy
t p CITY OF'GOSTA MESA • r
BUILDING DIVISION
> :
DECLARATIONS ., f• c Lp n
WORKERS'COMPENSATION DECLARATION: -
I hereby affirm under penalty of perjury one of the following declaations:
❑ 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:
(Th' section need not be completed if the permit is valued at one hundred dollars($100)or less.) , . - . „,_
[y 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 tobecome 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 rhes vislonss..
Applicant Signature: 1 Date: J9/rr/OY)
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED
THOUSAND DOLLARE(S1on,DDo),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F 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 full
force and effect.Llc.# Class If
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lender's Address:
Signature: - Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that Jnty {if cf lr q perjury that to E%Euct, FROM THE CONTRACTORS Lr any SE LAW for the following reasonce, (Sec.7031.5, pand Professions
permit
Code:Any city or coddty lT�c�h�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,rha�1 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 CodeVrAhat he or she iy 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 penaltyf.nit more than five hundred dollars($500).):
IV I,as owner of the property,or my.e ployees.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;faNContractors 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 aniemployees,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 amyl under sec. Business and Professions Code for this reason:
Signature: A II.
Expires:Oc Yt VOA/
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).
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 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 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&Permit for such construction or modification
from the South Coast Air(Duality Management District or from any other air pollution control district or agency? 0 Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑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 f inspection purposes.I agree not to occupy or allow occupancy of any building authorized by his pe Vnti final inspection.
(l6
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
ODE I INSPECTION TYPF p IHTmAL$ - ODE S INSPECTION TTPE 12AM 111/M6.LS
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 FirePrevention •
202 Final Factory Fire Place • . - ' 220 - Final Planning Approval • _
203 Final Dem 222 Final Site - - /
204 Final Demolition • 250 Final Building/Occupancyblicar WA
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CITY OF COSTA MESA •
li . BUILDING DIVISION -
. .j_ ,-' 11 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
�
. PERMIT
-`"b'oamost E04-01131
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 1650 SAMAR PL Status: ISSUED
Suite No Applied: 10/25/2004
Vicinity: BEDROOM Issued: 10/25/2004
Parcel Nunmber: 13928122
Applicant: REAL, M ATHENA ISSUED BY:
Address: 1650 SAMAR PL -- - _ ' ' ,
Phone: 714-91475020 -
COSTA MESA,CA ' . • Zip: 92626-3628 - ..
/ ' .
Owner: /REAL, M ATHENA - - y /.
Address i 1650 SAMAR PL "
� Phone: // OA
.COSTA MESA;CA Zip: 92626-3628YY��� �j
1
fir ' \ ,, \
Contractor: OWNER-BUILDER
Address: "
.. Phone: . - -
•
", . Zip' - . .
' license: 000000 -
- SCOPE OF PERMIT -
' , RELOCATE 2 OUTLETS.REF: 5 4"01807_ NT - ._ - - - ,
FEE SUMMARY
_ :Quantty_ - .- .
Quantity __ 2
`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) ' 'y , $0.00 0 Misc Electrical Equipment t- ,$0.00 0,.., ' _ ,a /
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 i. .:
Lighting`Fixts", • ,, \� $0.00 0 - - - • up to 50 kva/kw $0.00 0% ,�� ,/
Recept Outlets '$2.20 2 ;
DECLARATIONS fl /"1
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:
• section need not be completed if rhe permit is valued at one hundred dollars($100)or less.)
Ice 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
irrO: �--,provision;s
Applicant tf✓ I'riLr"e� Date:--,LP/2-S/0 'f
4WARMNG: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(5100,0001,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 am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full
force and effect.tic.It Class It
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she IS licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
sub' cts the applicant toe civil penalty of not more than five hundred dollars($500).):
C Lias)owner o'f 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 lieiself of 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 coCompletion,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,ai"in CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Lew 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 Genii-actors License Laws.).
.x.. it under sec. Business and Professions Code for this reason:
-Stgnature: i . L. ,tom!=�S'�1�
F�pires:"Otb D)/of
Verification of Ownership by(type of document,i.e.-property tax bill or deaJ.
,-
11e
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 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 permit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 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 ❑No
B (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE; I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-desc bed property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
/C/15/a`F--.-
L9Baitife.OLL.egal.Ow r(s) t"!.=^ Date.--.,vim'.
And/Or Authorized Applicant Date
•
PPE 6 INS& TION TYPF PAIS INTmAL$ ODE II INSPECTIONTYPE PAIS INTITIAIq
1616 Fixed System Final Fire Prevention - 206 Final Mechanical
1266 Pool Spa Final 2081Final Plumbing "ler
:LA4 i / 7
200 Final Re-Roof 210 Final Electrical 4 //�J_Mr✓�I,�w-
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 '
444r CITY OF COSTA MESA .
BUILDING DIVISION
F „,„ DEVELOPMENT SERVICES DEPARTMENT PER T NUMBER
PERMIT
Sbestatwo IP E06-01151
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa,ca.usCTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1650 SAMAR PL CLC Status: ISSUED
Suite No Applied: 10/13/2006 .
Vicinity: BATHROOM,KITCHEN,DINING AREA AND LIVIN Issued: 10/13/2006
Parcel Nunmber: 13928122
Applicant: REAL, M ATHENA
Address: 1650 SAMAR PL
Phone_: 714-914-5020 ISSUED BY:
COSTA MESA,CA _ - Zip 92626-3628 - -
Owner REAL;M 'ATHENA' "
Address 1650 SAMAR PL \ - _ " (2°
- _ it
17 K\ ' - Phone: 714-914-5020 ,��
/COSTA,MESA,\CA • - Zip:' 92626-3628 "'?'
/ / / / \ ''i 474,R
/ // \ N / '/�%! ; yr' ` 41'
f`
Contractor 'OWNER=BUILDER .4110m
�N /////," 'f46
��Address: fi• 5�
/: ' '
/ ' ' /!il i 'i/ Phone:. • 4
Zip:
- : License:000000 '
,t / ,, i _
' ,' f7 •> / -- = SCOPE OF PERMIT
ELECTRICAL PERMIT FOR ANINTERIORLIVING ROOM,KITCHEN,DINING ROOM AND MASTER
/BATHROOM'REMODEL.
� -
REF#:B06-01741' 2
1/
WORK TO INCLUDE:-19 LIGHT-FIXTS,_10,OUTLETS„7.SWITCHES.
.. - - - -FEE SUMMARY
'. •
Quantity f.'‘.-) Quantity -
1 N ISSUE'FEE t $23.50 ' jr./__N/, k*,, , _.,=� Temp Dist System'/Lighting . $0.00 0 " - ,
Temp service test', - $0.00 1: ---. --- -_ _ - _Busway/100 ft '__ $0.00 0
,tRes:a/c package. $0.00 ••:-. - - - -- _ • Standing Section • - - $0.00 0 -
New•Res,(1-2 units)',' ,, $0.00 0 Misc Electrical Equipment $0.00 . 0 _ •
Nevi 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 Fit \ \ `�.7." $20.90 19 up to 50 kva/kw $0.00 0
-
Recept Outlets,, . $11.00 10 „'-.,.\ up to 100 kva/kw $0.00 0
Switches\,', ` ' �� $7.70 7 -,-,,4%,, - over 100 kva/kw $0.00 0 '
pp \. - - Low Voltage Equipment $0.00- , 0
Non Res A I $0.00 I 0 .+1`"�`.i. -
Res Appl,"- -"' . A�:$0 00 0 `i/ , ' Low Volt Wiring System/Ckt $0.00' 0
Service to'200a, - \So;00��•t?,:.,-.".0, " „ ,.Mist.Conduit �; �_.:'.:'•; `$0.00' 0 '
Service to 1000av /� $0.00�C . 0' - j 6 Misc.Conductor $0.00 0
Service over 1000a //� $0 00A / -0.- ,Circus(gen or ride) . ' $0.00. 0
Motors to 1 hp v \o `- .$0.00 0 ' Circus(mech ride or lights), '. $0.00 ( 0 -
Motors to 10hp `A '' ,$0,00> ."--...210,-.-:_‘,� --Christmas Tree Stand- „$0.00,' "0 -
Motors to 50hp A' " �' i$0.00/ oma, _� o , Fireworks Stand , $0.00 0
Motors to 100hp �$0b0//�/i/'0_- -Other-Electrical Fee . • . $0.00
Motors over 100hp ,,,\1-4‘-,,/N$0.00�y/ 0
Communication drops N $0.00 /J`\0 " - ,ii-,-- Investigation Fee $0.00
Sub panel to 200a $0.00, 0'�., - ( Plan Check Fee -_ ,$0.00
Pole Light Pkg $0.00�..�0 K,:. Reinspection Fee ,$0.00
Sign Circuits $0.00 `-.- --
Sign � -'
Temp Pwr Pole $0.00 '0, 'mac-,- - TOTAL-CALCULATED FEES $63.10
Intermed Pole $0.00
•
•
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and-911'
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 V
2446-46(6/00)
•
DECLARATIONS U U
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:
Cartier: Policy Number.
(This.section need not be completed if the permit is valued at one hundred dollars($100)or less.)
$ I certify that in a 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,l,ws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,1 shall forthwith
comply with th ovislonn
Applicant.Slgnatu • C/"`" at Fr—
'"r""--`4
cA07/0 co
RNINO:,FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDmON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,end my license is in full
force and effect.Lie.tt Class If
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 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 fora permit
sub' is the applicant to a civil penalty of not more then five hundred dollars($500).):
I;las 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.It however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors 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)
I ursuant to the Contractors License Laws.).
❑ I a e- pt u sec. Business and Professions Code for this reason: 6
Signatur .-+ •
`"`--'^.— Expiresi^O� O�
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 Il 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 agermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LU 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 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 all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
B (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
t
CERTIFIC TE 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 a ree 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-des d prope r inspection pu I a ee not to occupy or allow occupancy of any building authorized by this permit un}}il final inspection.
Signature Ot;Lega Owner(s)—-'--- bb( LD to
And/Or Authorized Applicant Date
;ODE# INSPECTION TYPE DAIS IffrrTIALS CODE( INSPECTION TYPE PAIS amnesia
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final _ 208 Final Plumbing. •
,,/'—
200 Final Re-Roof 210 Final Electrical 7 r
201 Final Block/Retaining Wall 212 ' Final Fire Prevention
1 /✓ I , ./rr5
202 '",Final Factory Fire Place 220 Final Planning Approval - .
• w
203 Final Sign 222 Final Site .
204 Final Demolition ' ' 250 Final Building/Occupancy
iL ,
7'rt 5. 'LI}Y OT COSTA MESA , •
BUILDING DIVISION
>4 .DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
4. 7I
•
'hiPERMIT
ptet„, p ease E05-00496
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us ' 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 1650 SAMAR PL Status: ISSUED
Suite No • Applied: 05/23/2005 •
•
Vicinity: Issued: 05/23/2005
Parcel Nunmber: 13928122
Applicant: REAL, M ATHENA ISSUED BY:
Address: 1650 SAMAR PL ' -- - - �'•��':�
.""4:4•:';-32(2--:-.- 1\---' I, Phone: '714-914-5020.! ^ _'7 .
,r•'^F->- -`..
COSTA MESA:.-CA,- \ m \ Zip "- 92626-3628 .., r :..t.
Owner's REAL MATHENA--,--<:_-.::%:-----' �:� \ •Nye
Address= 1650 SAMAR PL `;`� Ii-
RR r
s L•
...t �7.�_ Phone: �`
.,
COSTA MESA,CA Zip: 92626-3628 Y I'/_ hi
, '`
' Contractor: OWNER-BUILDER i•. '
':
- r Address: :4.27;. . ( , `.Yr
Zip
• r`- License:000000
SCOPE OF PERMITS 0,1,- S '
- • ';;ADD LOW VOLTAGE-LIGHTfING,TO EXTERIOR OF SiF:D.'LOCATED AT FRONT AND REAR OF ' - `
.PROPERTY. - - - - y',
ti
- ,,,ELECTRICAL TO INCLUDE: 1-LOW-VOLTAGE EQUIPMENT AND 1'MISC CONDUIT: - 5, ,
- ' FEE SUMMARY . ., -- • ,
'Quantity .../7 Quantity + f
' ISSUE FEE - $23.50 Temp,D st System;/Lighting $0.00 0 `';, J i '
Temp service test $0.00 Busway/100 ft - - $0.00 ;�',
Res.a/c package; ' 1 $0.00 -�.,. 'Standing Section '$0.00 ' -`%.01,' ("T-. / "r*1 r
' New Res'(1-2 units)' • $0.00 0 7 1 '.•'• Misc Electrical Equipment $0.00 :'0 , '
New Res(3+units) `‘; •4$0.00 0 .. Transformers up to 1 kva/kw $0.00/ 0
Pool/Spa, - ' $0.00 0 _ • - up to40.kva/kw $0.007/ 0 - il
Lighting Fixts 1 $0:00.r t0:`� - r - " up'to 50 kva/kw,t $0.00 0 .. -� i„'/
Recept Outlets / $0 00-2-'�C 0-;; `121 , 'up to 100 kva/k`w . i$0.00 ,- 0
\ $18.-20-</c/.1'
Non Res Appl i. $0.00- r\'^o c- ; Low,Voltage Equipment $18`20 K- 11' /, \ /
Res Appl ' $0.00 0�' � Low Volt WmngSystern/-Ckt /4-,-.$0.007 0 i; �
Service to 200a i ,i4$0;00 / 0 "_ : Misc Conduit" CSA 1 $18.30/ „--1/,,l',/
Service.to.1000a C x-$0.00'2 -2/' 0 - -Misc Conductor VA-;-$0.00 „../7-B/- .....
Service over 1000a .1,,,$0.00 1r;0 ,. "sr:-, " _ Circus(gem,or ride) 1 "$0.00;4 ,-40
Motors to 1 hp -$0.00 0 . - , - �Circus'(mech nde or lights) $0.00. 0
Motors to 10hp $0.00.. ;_ 0 Christmas Tree Stand' ---;%j$0.00 0
Motors to 50hp $0.00 - -0 _ - Fireworks Stand _ - - "$0.00 0
Motors to 100hp $0.00 0 =-'_ - --- ;,-. --..- Other-Electrica6Fee" ..--" $0.00
Motors over 100hp $0.00 0 - - ..-.•.,;44-.4.-..,_ _ __ �'- -- -
• Communication drops $0.00 0 - Investigation Fee $0.00
Sub panel to 200a $0.00 0 Plan Check Fee $0.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6r00)
,
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 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 leas to become subject to the workers''
compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DO LABE($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 licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.tic.4 Class 0
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 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 anil Professions
Code:My 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
ode: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:.. ,,,/ 0f ate.'`t'DS-r3-0.�
1 9flh-IDverified by drivers license. yQYes 0 No fs'Llians_e No. f iEnpires:egAV0W
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 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? 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 a permit 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 IJ No
(Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correI 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- scribed property for inspe ti gyposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signetureer(s)y .��-�"i�"%rpc_:._ Date:-S-1 -
And/Or Authorized Applicant Date
cODE 0 INSPECTION TYPE • ' .. ' ' • ' ' -' Old ' ANIMALS ' ' CODE I' INSPECTIONTYPE' • - PAIL IN)II16L5
1616 Fixed System Final Fire Prevention -206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing '
200 Final Re-Roof • • ' 210 ' Final Electrical - .
•
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 • Final Factory Fire Place ' ' - 220 Final Planning Approval -• ' .
203 Final Sign 222 Final Site __.
204 Final Demolition250 Final Building/Occupancy '
sly 44, CITY OF COSTA MESA
e_. _� �6 P.O.BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 92628-1200
i
j DEVELOPMENT SERVICES DEPARTMENT
'hen
APORPTEO T¢a BUILDING DIVISION
EXPIRED PERMITS
October 9, 2006
M. Athena Real
1650 Samar PI
Costa Mesa, CA 92626-3628
PERMIT NUMBER: B04-01807, E04-01131
FOR: Window Change-out& Relocate Outlets
PROJECT ADDRESS: 1650 Samar PI., Costa Mesa
This is to advise you that since the above permits have expired, fees would normally
be charged reinstate the job. The fees would be equal to the fees charged to pull
new permits. However, September 5, 2006, we began the Residential Remodeling
Incentive Program #2 and if you come in to the office to pull permits by December
15, 2006, the fees will be waived. After December 15, 2006 full fees will be charged.
If you have any questions, please contact the Building Division at 714-754-5273,
between 8:00 a.m. and 4:30 p.m., and a staff member will assist you. We appreciate
your working with us to resolve this matter.
Sincerely,
574.1)
Ma Jane Weidenkeller
Office Specialist II
Building Division(714)754-5273 • Code Enforcement(714)754-5823 • Planning Division(714)754-5245
FAX(714)754-4856 • TDD(714)7545244 • wTvw.cLcosta-mesa.ca.us
Via Personal Delivery
M. Athena Real
1650 Samar Place
Costa Mesa, CA 92626
October 6, 2006
Mr. Ed Petros, Chief of Inspections
Building and Safety, Second Floor
77 Fair Drive
Costa Mesa, CA 92626
Re: Reinstatement of Permit Nos. B04-01807 and E04-01131
Dear Mr. Petros,
I am respectfully requesting the reinstatement of my above-stated permit numbers. I had
to discontinue the work due to financial hardship.
Please feel free to contact me should you have any further questions. I may be reached at
714-914-5020.
Regards,
M. Athena Real
i1 CITY OF COSTA MESA •
BUILDING DIVISION
:4- ... ,i DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
F t w:w�4. 1
PERMIT
°Ppq"`O PO4-00709
•
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 1650, SAMAR PL Status: ISSUED
Suite No Applied: 10/25/2004
Issued: 10/25/2004
Vicinity:
ISSUED BY:
Parcel Nunmber: 13928122
Applicant: REAL, M ATHENA:, - • " ' - ,
Address: 1650 SAMAR PL ' ..
Phone: 714-914-5020 - -
COSTA MESA,CA Zip: 92626-3628
. -
Owner /,REAL, M ATHENA '
Address 1650 SAMAR PL- -
Phone: - ,
COSTA MESA,CA Zip:,_92626-3628
,. ,
` Contractor: OWNER-BUILDER " • �- -
., Address: . , • , ,
Phone: _ - _ - .
•
Zip:
N
License: 000000
''
Arch / Eng : ,'r .1. _
,/ _,/. _r ' 1, N
Address: . - - _ • --- • -
Phone: _ .• .. ., .. •
.. . Zip: _ -. ..
_ - '- -- i -
- -
�, - _ SCOPE OF PERMIT
'�,; RELOCATE WATER SERVICE. REF.:B04-01807 ,ve,/, i. /
\ `` FEE•SUMMARY
- ` ' 'AMT •rQTY ��` ,AMT QTY
AMT QTY + '�` _
ISSUE FEE„. - $23.50 Laundry Tub/Washer. ` $0.00 ''-r0 n p P
_ Sumum ,p ' $0:00 0
Backflow irrigation $0.00 '-, 0 -. ;-Landscape Irrigation- $000 0 ` Swimming Pool '1,P; $0.00 0
Backflow Preventer $0 00 "0 , P-Trap ,;• ' [ = =$0.00 0 Trap-Primer. $0.00 0
Battub `-" ,./-$0'00 N 0. - Pressure Regulator $0.00 - "0 ,Urinal �- - . �- / $0.00 0
Clarifier Systemic /40.0077 _ 0 Process,Piping(per 10 ft)` $0.00 0 -r., 'Vacuum Brkr Bkflow(1-4) $0.00 0
Connect(Ice,Soda;etc)\ $0.00'',-0 _"Receptors' ", - -'$0.00...-r-0 -C' ,Vacuum Brkr Bkflow(5+) $0.00 0
Dental Units '$0.00 i- 0' Septic Tank' '- _ =-$0.00 - '-0 - ' l WashmBasin, '�, 2 $0.00 0
Dishwasher , $0:00 " .0 ' Sewer Cap for Demo - -$0.00 0 , , Wash Basin Set' $0.00 0
Drain, Floor '$0.00 0 ..' . `Sewer Connect $0.00 0- , ' 'Waste and Vent System $0.00 0
Drain,Rainwater $0.00' 0 - 'Seweh,Private Line ' / ; $0.00-0• - Water-Closet(Toilet) $0.00 0
Drain, Roof $0.00 - 0., --Snower' - - $0.00 . 0 ' ,Water Heater/vent $0.00 0
Drinking Fountain $0.00 \-0P;' ` Sink,bar- ' -,\. r . $0:00 -0 ' '•'Water Piping(Inst or Rep.) $0.00 0
Expansion Tank $0.00 0 _ Sink,commercial $0.00 ,0;i ': ,_ - Water Re-pipe $0.00 0
Gas Earthquake Valve $0.00 0 Sink,'Floor - ---22,-2/$0:00 ' 0 - Water Service $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. rias/ ^7.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicabllefoodesrend all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiratidri.ot t iii permit.
FOR INSPECTIONS CALL: (714)754-5626
244646(6/00) .
DECLARATIONS (1
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 career and policy number are:
Carrier: • Policy Number:
(Th)s sect/on need not be completed/l the permit is valued at one hundred dollars($100)or less.)
Of 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 ws 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 the a rovisions
Applicant Signature: Date: /0/1-3-/0 IA
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED
THOUSAND DOUARE($100000),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 under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full
force and effect.Lie.8 Class a
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
sub)acts 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 e�yceem,,pt under sec. - Business and Professions Code for this reason:
Signature:o f) /CiL /�
Expires: Di/01 ore
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,1alsework,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 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 ❑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 aRgermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U 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).
8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-d cribed property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
0` /Iv�e /o �l
Signature Of Legal Owner s) Date
And/Or Authorized Applicant Date
CODE INSPECTION TYPE PATE 1NTITIALS CODES- INSPECTION TYPE DATE KUM/
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing c,'9_11-64
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'OFCOSTA MESA . ,
e°,� r,
n,i(#t)
BUILDING DIVISION'
(" it--4 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
u 041
, PERMIT B05-00815
ttbettonn„°s# l
(714)754-5273.• Fax(714).754-4856 • www.ci.costa-mesa.sI91LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1650 SAMAR PL Status: ISSUED
Suite: Applied: 05/24/2005
Vicinity: SLAB AT FRONT SFD Issued: 05/24/2005
Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N
Parcel Number: 13928122 Zoning: R1
Applicant: REAL, M ATHENA — - • L�
Address: 1650 SAMAR PL - _ - ' ISSUED BY:
-s,�/' - -" ' -- ' . Phone: 71'4-914-5020 a-=
COSTA MESA;CAL-'.,= •t \ Zip: ;92626-3628^`'
,an•;- —'1 ' 1 1 ' a
. Owner REAL;M"ATHENA --, i
Address 1650 SAMAR PL \ { - ,ti
\ / -'r --� Phone - ` v,
./.;-, COSTA MESA,,CA "j - Zip 92626-3628 � .` V 7'�
r
Contractor: OWNERUI
BOLDER ' ) �- ' \
Address:''= �R1`v; A /
�
-'.�.� _%
,-,'Phone:
Zip: �' %�'"/17 1 'License: 000000 ,vV�, =
i,//i .. _
_ "
Address: / h;,,y 4, ';' I''- - '—- _ Address: .
, ci t _2.
Phone- Phone:
1----
. ' ',Zip: 'License: - , Licens :
e ' - -
' 'I 1/ -s;,r,-,(.f 4.,ThSCOPEOF>PERMIT` -r,-; ,,',,. ; I _ v
• CONSTRUCTION.OF A FOUNDATION(16'5^'X 21 S'SLAB)FOR FUTURE SINGLE=STORY ROOM ADDITION AT THE.FRONT OF-AN EXISTING
x SINGLE-STORY SFD. —=—= w __Y.... _ .. -- - - . -. ';. :� L.._._
;-NO OTHER WORK AUTHORIZED WITH THIS PERMIT.- ---c---i --
a r'1 I ,
-� FEE SUMMARY - ` ' '
Plan Check: ' `''$45.01 i - Calc Valuation ,'i, f t -$2,000.00
Permit: '$69.25Claim Valuation: '.,•; .$2,000.00
SMIP Res: $0.50
SMTP Com: '$0.00 ' /
• Other: '$0.00
-.,- r', / {;E
Inspection $0.0.0
7 /
Total. $11476- ,.� ''v��✓ - /
/; �.--„,. ti PLANNING &ZONING'S - ' �;/'J
-'`
SETBACKS �; • _ .,..-2::.:-.::::--
v
MAIN STRUCTURE Front -0 0.: (./r,. / Rear.....:01'15C
..;00 Left -04.. ,---\ Right t'0'0 4, - •'
ACCESSORY Front 0-0` Rear 0.0 LeftV ' 0- 0 , L-1 } Right„„„--;020:
PARKING Existing: 0 Required: _ 0 Proposed: 0 - /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 authorizedunderthis permit to be considered.legal, such work must comply with all applicable codes, and all
required.Inspections and.flnal approval must be obtained.Failure-.to-obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626-
2446-46(6/00)
DECLARATIONS ( N) ( N1 -
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:
r�(T(�`}��section need not be completed if the permit is valued at one hundred dollars($100)or less.)
rig
that in the performance of the work for which this permit is issued,I shall'not employ any person in any manner so es to become subject to the workers' '
compensatlo laws of Califomla,and agree that if hould become subject to the workers'compensation provisions of Sec' n 3700 f the Labor Code,I shall forthwith
comply with 1 rovision -/ � ) /yao `` D
Applicenl.Sign�arije '(.G(GLLQ� Ql,? L(.\ D�e:a- 47 05
—Pc-
WARNING: T SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML 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 licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full
force and effect.Lie.# Class#
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 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 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
old 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.).
- L 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 rsuant to the Contractors License Laws.).
❑ I am exe under s . Business and Professions Code for this reason:
SignaNree: '-'
/ E.5;010-0' 2- DP
Verification of Ownership by(type of docui.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? ❑Yes 0 No
(Section 25533 of the Califomla 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 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 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 Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by Califomia 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
ve-desscc}ribbed p��p:re f r ir�y��tioonn p(�rPoses.I agree not to occupy or allow occupancy of any building authorized by this p(ermi nail/fine ns afar.
2-1
Signature Of Lew gal' /Date
And/Or Authorized Applicant Date
'POSE I INSPECTIONTYPE. - • p6IE' - INTmALS - ' ' CODEI INSPECTIONTYPE ' " . -•-• - . - -PAH • • INTIML$
1616' Fixed System Final Fire Prevention' - 206 Final Mechanical • -
1266 Pool Spa Final 208 Final Plumbing •
200 Final Re-Roof . . , 210 Final Electrical
201 Final Block/Retaining Well 212 Final Fire Prevention
202 Final Factory Fire Place - 220 Final Planning Approval'
203 Final Sign 222 Final Site
•
204 Final Demolition 250 Final Building/Occupancy ' (n—I.i
10940 e EE RECTI}!t�
COSTA MESA BUILDING-SAFETY DEPARTMENT
eG/ /7,-"y� -.3--7P.
O.BOX 317. COSTA MESA. CALIFORNIA FINANCE DEPT.
- ---" Y "� CITY OF COM MESA
i' FOR APPL/CANT TO FILL IN COMPLETELY ; APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
5 BUILRESSDING 1650 -.Samar Place
ADD
COSTA MESA, CALIFORNIA FOR OFF/CE USE ONLY
•
RECEIPT NO. M
PERMIT- r
OWNER Glenverde Homes, Inc. SLFEI,T N
1
MAIL - Box 65 . •
RECE ED BY 1 DATE RECE VE.DP� DATE ISSUED
ADDRESS 11��nn /i/9JV`'f NOV 9 S ,a54
° CITY Balboa 1sland,Calif. TNOQr3-4220 BUI EISS /
ARCHITECT LIC.
ENGINEER ENGINEER NNO. COSTA MESA, CALIFORNIA
I
ADDRESS brA ZI GROUP��er
- pp p ZOO ENE TYPE �J/
'FI
CONTRACTOR Macco Cp� LIC.NO. 98808 APPROVED
BY DATE
ADDRESS Box 65, Balboa Island,Calif. ZONING OW
°, LEGAL LOT 09 - 8p I EO / I NO.OF I UBE OF NEW M
109 IBLOCK TRAC��V� - PLANS BUILDIyctic A
q DESCRIPTION NO. //�� Q( W f/�y 1 (
I APPROV�� 9
J (m
A.P..NO., SIZE BY DATE' I'._ ,J
OF LOT 7000 I NOW ON LOTS G S
E REQYARUUIREDV ALLOWED
!' USE OF (CENTER LINE ST.)
, EXISTING BLDG. FRONT _CZ) FT. IN.
~ SETBACK LINE FROM e ° ..........
CENTER OF STREET 70 REAR YARD 31 ° R.SIDE 'J FT. IN.
F SIDE YARD ILEFT 5 IRIGHT L.SIDE FT. IN.
e DESCRIPTION OF WORK �f -1---' IN.
., REAR
5 NEW IX II ALTERATION I I ADDITION I
R REPAIR I ' II MOVING I NO.OF pI DEMOLISH I
o BUILDING 15011/1130 ROOMS U STORIES 1 ° .
. r.
EXTERIOR W . ROOF
COVERING tit ti (COVERING rock •
, USE OF BUILDING AND WORK TO BE PERFORMED ///
• reside �'LTJ/Qi�
•
0
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ! THE UNDER VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM. ' THE AMOUNTE SHOWNESTABUNDERSHING A PERMIT FEE ONLY.
• PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
a, BUILDING CONSTRUCTION. VALUATION
I SIG - -E OF_ el NVERDE HOMES, INC. o PERMIT FEE $��"�
, P ' MITT'E ° 6V
.10";,...pp Ior
� PLAN CHECK $ /7L57)
sip
31
/ Y a+AUT ( �a! a at% � t TOTAL FEE $ 0' O. 60
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