HomeMy WebLinkAbout1128 SEA BLUFF DR - Building Permits s-
...,;51-111:!".. .„. CITY OF COSTA MESA
! `� BUILDING DIVISION
). F i DEVELOPMENT SERVICES DEPARTMENT PER NUMBER
, air�laPERMIT• 05-01456
e`.
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.9hJ$LDING PERMIT 74-6 R DRIVE,COSTA MESA,CA 92626
Job Address: 1128 SEA BLUFF DR ` Status: ISSUED
Suite: Applied: 08/31/2005
Vicinity: ROOF Issued: 09/01/2005
Primary Occ: R-3 Dwellings/Gong Res<10 Type of earl).n:
Parcel Number: 42232211 (mime:
Applicant: YOLANDA HUAPAYA • /
Address: ' .
Phone: 1 714-393-6251 ISSUED BY: .1.11.11--d
.Zip: -
Owner CALHOON, RORY D • '
Address 1128 SEABLUFF DR
--_-Phone: -/ �
COSTA MESA,CA , -- — - Zip::--92627-4068 -, -
1
Contractor "MC CORMACK•ROOFING
Address: 4091.E LA PALMA";
• PALM
AT,'"
„,://-,1:- Phone: (714)630-5543 \ -% . � 7
. . ANAHEIM",-,CAT”' � \�
Zip: . 92807 sr'-/ .>License: 643700 ,i.;,A
�C \; - ,\ .K
Arch , , 7-,: • r Eng: - ,._ A;'� t„.....-- \ \A`
Address: ,,i� -. • 1 '`. 'Address: - \ � `�
Phone: ` `\ r, —Phone.
Zip: '-_License: - — - License: • ,,,
\?,
SCOPE OF PERMIT r ,
TEAR OFF EXISTING ROOF.INSTALL 1 LAYER OF 30#FELT,50 YEAR OWENS CORNING COMPOSITION SHINGLES,AND REPAIR/REPLACE
SHEATHING AS NEEDED.24 SQUARES.- • - _. _ _ -
,:. ,1. . _'FEE SUMMARY_ i/; ; ;') `-,
Plan Check: " $0.00 - , Calc Valuation: •,'l • $3,600.00
Permit: $97.25 Claim Valuation: • ' • $3,800.00
SMIP Res: $0.50 " 7 i •
- SMIP Com: • $0.00 -"`
Other $0.00r i
`Inspection: $0.00
,i
Total $97.75 2,'/ ) ' '
Y
1
" V - " t51PLANNING &ZONING =, % / '
SETBACKS v : ,r ' 'r
MAIN STRUCTURE Front-, 0 0 ,1•7‘-'7"'Rear• 0-0 . . .",Left , 0 0, - `,: '"Right 0 0/ �, /
�'
/ACCESSORY
��� Front .pro � Rear - 0-0_ -: .�Lefi' 0-0 Ri ht' 0 0"</,,,---,
i
PARKING A; Existing: : 0: :
E - Required 0> , Proposed:—= 0- A. " '
- -_ � V�-..t �j•� .
L
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
fora period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
DECLARATIONS n4' = ;; (•
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.
Thave and will maintain workers'compensation I surance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
i--My a rtpensation I a mer a7 II nu{� 0 ^ l' 'L1L�1, /
-Ca e Cu� n �. J4-J 1/ i yK - -Pali 1 ✓T 14 4q
v(This sect/aaalll need not be complete r e permit is lued et one hundred dollars($100)or less.)
trriCet
❑ I certify that in the perfo ' .nce of thgqkwwd fo 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 C. ornia, - d' g' , at If I should become subject to the workers'compensation provisions of�@ccc{{{IIIon 3 00 of the Labor Code,I shall forthwith
comely with these;rovi Ii i.i itt.! /�1 1 ��
. Applicam'Slgnature:: • 4Ihe ® r -- Date: V 1 � O
WARNING_FAILURE T• SEC -n WORKERS'ODMPENSATIOf�I,•VE- IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL ES AND OWL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE 100,••l).IN ADDrON TO THE COST OF no TION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
`,,, �_
LICENSED CONTRACTORS DECLARATION: '-YF' }:,z 4 z
''-•'t-'YTn
I hereby affirm that I am kens-d u••- r• i 0 hapter 9(commencing wfth Section.7000)of Division 3 of the Business d rot sio e,and my license Is in full
force:and effect.Llc-fl �i-� �/ _ Class ti
Cs to tractor's Signature:KLA1TOR)��'� PAO 4
,Class
1
CONSTRUCTION LE • 'GENCY:
❑ I hereby affirm that - -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 and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or Improvement Is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,I.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,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 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 apemit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? L-I Yes LJ No
(Section 65850.2 of the California Government 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 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 duality 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
6 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Si` store Of Legal Owner(s)
yDate
0/Y- `
rAu on d cant-_mss, TIC fi e"------ -
INSPECTION TYPE L r RML =AUCODE II D SPECTION TYPE PAIL 9i®!Ld
161 Fixed System Final Fire Prevention \V. 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
/� !
200 Final Re-Roof _'7—/7 29" 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
•
41 CITY OF COSTA MESA-.
Ws,
BUILDING DIVISION
). K�et l q DEVELOPMENT SERVICES DEPARTMENT. PERMIT NUMBER
PERMIT
1304-00285
;` r
Aenoc'Sc
I
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.cBUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1128 SEA BLUFF DR - Status: ISSUED
Suite: Applied: 02/02/2004
Vicinity: RESIDENCE AND ATTACHED GARAGE Issued: 02/02/2004
Parcel Number: 42232211 • Zoning:
. Applicant: HITCHCOCK, PETER
Address: 6951 NEWTON AV
Phone: (562)634-8470 ISSUED BY:
LONG BEACH,CA Zip: 90805
Owner: CALHOON, RORY D0.9
Address 1128 SEABLUFF DR .13‘
Phone:
�.fl •
COSTA MESA,CA Zip: 92627-4068 �' e'•°
o to ��'1
Contractor: OLSEN ROOFING COMPANY `'1� ,43 ''`
Address: 6951 NEWTON AV s'',rtVt. �,�4. :�,�;y.i ii
Phone: (562)634 8470,7}_p} �ASs. A sy++
LONG BEACH,CA "'i1 +(�Fl�t'o a'du +' 9r fr v'
Zip: 90805 License: 2541,49 e"3' t , 'c)�
Arch • n}�z2 g"�y,,„��� S
Address: ,viii' ,��>� ;'�'(xArddr,.743 , Et�ft fr
a 46;;-,' e:, ry '� u• tc, Phone:
e.
Zip: roile+'�?"�{ tL�icensetY:/ tat} 4k".4117,141
' �r f I, (t7' License:
An#°A,r x,;!',11 l4"`:SCOPEIOF•PERMIT
REROOF REST ENCE,AND"QTJACHED GARAGE I/O EXISTING4CED4R SHAKE ROOF,REPAIR/REPLACE SHTG AS NEEDED, 1 LAYER 15#
FELT,APPLYppr30,YEAR FIBERGLASS COMP,SHINGLES.'23'SQUARES'+Sf 1Y
P +f;5�ii7 p're'y -'4 .f .'"1 fi•'Y3
O$ I c f = FEE SUMMARY
Plan Check $0 00 es,, -i,1% .;:4,1-x Calc Valuation: $3,837.00
PerMit $97.25;44/ h j Claim Valuation: $3,837.00
SMIP Res '1, $0 50tyt'
SMIP Comyr; $000°°
Other.' $0.00
• w4 !,irr,
Inspection:�.�n�.�a{�$Oi00
7
'
Total: $97.75
PLANNING &ZONING
SETBACKS
MAIN STRI ICTt IRF Front 0-0 Rear 0-0 Left 0-0 Right 0-0 •
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 •
PARKING i : 0 Reauired: 0 proposed: 0 •
NOTES:
•
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or it 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 t6/e01 ,
'oECLARAT/ONS (,� }.; xvc q z u yx y :*« rY4 I
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 sell-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 penormance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(Ibis section need not be completed if the permit is valued at one hundred dollars(5100)or less.)
❑ I certify that in the performance of me work for which this permit is issued,I shall not employ arty person in any manner so as to become subject to the workers'
compensation laws of California,and agree that if I snould 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 DOLLAFE(S1090001.IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF TIIE LABOR CODE,INTEREST;AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensee 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.u Class w
•
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 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: rr Date:
do cr./
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.(cornmencing with•Sectlon 7000)of Division 3 of the
Business arid Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any%deletion of.Sectton'9031.51by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): „yv`. •'A"y'"`
❑ I.as owner of the property.or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is no[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 orImpro4es 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 tff however,the building or improvement is
sold within one year of conipietion,the owner-builder will have the burden of proving'thathe orrshe did not.build or improve for purpose of sale.).
:R,"„to con 'r v ( J
❑ I.as owner of;he progeny.am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to bonetrucl the project(Soc'7044,Business and Professions
Code:The contractors License Law does not apply to an owner of propeny who builds'or.impioves thereon,end who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.). .4'rCiNs,rS
f ! : i
❑ I am exempt under sec, • fiBusiness and professions Code for this reason:: • 1 ! I
Signature: SC : deF�+, . r: + ri jz Date PHI 1-1- 1
Owner ID verified by driver's license. ❑Yes ❑No •!`'r {'.Divers License No h ' f j Expires:
Verification of Ownership by(type°Ldocument,i.e property tax bill or deed)k,-i i ��k• +:.3r-^-"`” ) <(
, 'F
DIVISION OF INDUSTRIAL fSAFETY,PERMIT,CERTIFICATION: 'tr. ".f ( -r=*+;5)yi?
❑ I hereby certify that no excavation five(5)'or more feel in depth into which a•person is required to descend,will be made in connection with work authorized by this
permit,and that no building strucluretscaffolding 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,Caflornia'Administratise Code) E r 11/-. , s;1
4.
•
" Lii
❑ As owner-budder.1•wlilfnot 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. ; x.
Signature: rte:t :r *t ;- Date: tr
Division of Industrial Safety Permit Number. \:-.>'a#+''r-'
•
HAZARDOUS MATERIALSANDEMISSIONS CERTIFICATION:
I Will the applicant'or present or fuuire.building occupant need to file and certify a Business Plan tar emergency response to release or threatened release of a hazardous
material? 0 Yes•:`-40 No"-✓
(Section 25505 of 1he'Califomia"Health and Safety Code requires. with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a ieported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons.
or 200 cubic feel of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Depanmenl by each business which at any
ono 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)?
0
(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 RIAPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑No
5 Does or wilt the applicant or present or future building occupant require for the work which is the subject of this application ayermit for such construction of Inodilicalion
from trio South Coast Air Quality Management District or from any other WI pollution control district cr 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 pail of gm facility to be constructed under this permit be within 1000 foot 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 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
8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penally 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: Dale:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and slate that the information given is
Doirect, ! agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa lu enter upon Ine
abovruescnued 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
AndiOr Authorized Applicant Dare
CODE r INSPECTION TYPE DATE INiITIAL CODEX INSPECTION TYPE - PATE INTnIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1?bb Pool Spa Final - ,.;�x .� 4 Siry l- •� 208 „ Final'Plumbing ;' + "' "'' ll +*�-"
200 /1 Final Re-Fiool w'> •"d"� !� ° ` '1n`-'1 -'•"• '1'"s+f -h` 2101.0;col Finan ElectriCel �y'•:( y rA-;1�,x. +feJ ikv
t - 1 tt t tA7y� .P 4t xl::,i r4J vs n i,-,.
201�(• Fmel Block/Re aining Wall I, 212 { Final Fae•Prevention'may '}'` a r 41:k'
202 F•ina• l•Factory Fire Place" rr . > r2r''>,i !4 1 r;hl_ ' 'Approval pP z v
lc_.,r 220FY Ffnal PlanningA roval yrJ}"k : y`
l• , t .7
203 \ -
Final Sign' .'' '' M "�"'+"'� 222 L Final Site
_ ..r a• 'Lxylv '‘._ t H
204 Final Demolition- Sl -r .•., 4." "' r
250Gd:..Fnal Building/Occupancy
p ' CITY OF COSTA MESA
4 -M'6
BUILDING DIVISION
Y•1 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
�t /; PERMIT /
"NI / / B04-00387
•
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 1128 SEA BLUFF DR Status: ISSUED
Suite: Applied: 02/20/2004
Vicinity: Issued: 02/20/2004
Parcel Number: 42232211 Zoning:
Applicant: CRAWFORD, SCOTT ISSUED BY:
Address: 1306 E. POMONA
Phone: 949 855-0180
SANTA ANA,CA , , Zip: 92705
Owner: CALHOON, RORY D
Address 1128 SEABLUFF DR -
Phone:
COSTA MESA,CA Zip: 926274068
Contractor: CRAWFORD CONSTRUCTION
Address: 1306 E. POMONA
Phone: 949 855-0180
SANTA ANA,CA
Zip: 92705 License: 349757
Arch : _ : - Eng:
Address: Address:
Phone: Phone:
Zip: License: • License:
SCOPE OF PERMIT -
CONSTRUCT 450 SQ.FT. GUNITE POOL&SPA') / •
FEE SUMMARY
Plan Check: $320.29 Calc Valuation: • $35,000.00
Permit: $492.75 Claim Valuation: $35,000.00'
SMIP Res: , $3.50 •
SMIP Corn: $0.00 •
' • Other: $0.00 •
Inspection: $0.00
•
Total: $816.54
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 0-0 Rear, 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 Proposed: 0
NOTES:
•
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
•
DECLARATIONS co l a
WORKERS'COMPE.NSATION DECLARATION: f ,
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.
tO
V ' My wor(kDr�.'ccom ansaAfton Insurance carrier end policy number are:
Carrier: Jz i( may) Policy Number: I/D(a257 4�✓3
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the (L� ormance of the w• •r which this p• mit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation law • California,and at e: hat If I sh'uld%:come subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these • •visi•n
Applicant Signature: II k. -a.s e A Date:
WARNING:FAILURE TO S: URE WORKERS'•`MPENSATI• e••V:-•GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND COLLARS(SI•.,000),IN ADDITION TO THE COST• COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am lice;d under prA,ons of Chaster 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.$ — / Class# 57 7.7 9-/,
Contractors Signature: ,IS!SS �� Date:
CONSTRUCTION LENDI ' 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 end 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 tile a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes ❑No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
O As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the Califomia Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at 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 end 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
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apgormit 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 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 Califomia Health and Safety Code).
7 If a permit from the South Coast Air Duality 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 a• - to comply with all state laws an. ity ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-desd property for• spection purpose I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
ip- /
.turesegalwner(s)
to
V�� Ig / '` Zv'1y
/ . . •r_utodz:•Applcant ate
CODE* IN-'ECTIONTYPE PATE JNTITIALS CODE* INSPECTIONTYPE PATE =ALS
•
1616 Fixed System Final Fire Prevention p � 206 Final Mechanical
1266 Pool Spa Final it'.
t �T
i 1
' LJl 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
p CITY OF COSTA MESA
4 66 BUILDING DIVISION
F a. -
DEVELOPMENT SERVICES DEPARTMENT P MIT NUMBER
PERMIT E04-00165
%known d
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 1128 SEA BLUFF DR Status: ISSUED
Suite No Applied: 02/20/2004
Vicinity: Issued: 02/20/2004
•
Parcel Nunmber: 42232211
2
Applicant: CRAWFORD, SCOTT ISSUED BY:
Address: 1306 E.POMONA ,
Phone: 949 855-0180
SANTA ANA,CA Zip: 92705
Owner: , 'CALHOON, RORY D . •
Address 1128 SEABLUFF DR
Phone:
COSTA MESA,CA Zip: 92627-4068 ,
Contractor: CRAWFORD CONSTRUCTION
Address: 1306 E. POMONA
Phone: 949 855-0180
SANTA ANA,CA Zip: 92705
License: 349757
SCOPE OF PERMIT
REF: B04-00387.CONSTRUCT 450 SQ.FT.,GUNITE POOL&SPA;ADD 1'OUTLET FOR GAS BBQ
• FEE SUMMARY
Quantity - _ : _ _ - - . Quantity
ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0
Temp service test $0.00 Busway/100 ft $0.00 0
Res.a/c package $0.00 Standing Section $0.00 0 ' .
New Res(1-2 units). $0.00 0 Misc Electrical Equipment $0.00 0
New Res(34-units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $49.50 1 up to 10 kva/kw $0.00 0
Lighting Fixts $0.00 0 - - up to 50 kva/kw $0:00 0
Recept Outlets $1.10 . 1 .. up to 100 kva/kw $0.00 0
Switches $0.00 0 _ over 100 kva/k_w $0.00 0
Non Res Appl $0.00 - 0 , Low Voltage Equipment' ' $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0
Service to 200a $0.00 - 0 Misc.Conduit $0.00 0
Service to 1000a $0.00 0 Misc.Conductor $0.00 0
Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0
Motors to 1hp $0.00 0 Circus(mech rideor lights) ' $0.00 0 .
Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0
Motors to 50hp $0.00 0 Fireworks Stand $0.00 0
Motors to 100hp $0.00 0 Other Electrical Fee $0.00
Motors over 100hp $0.00 0
Communication drops $0.00 0 Investigation Fee $0.00
Sub panel to 200a $0.00 0 Plan Check Fee $0.00
Pole Light Pkg $0.00 0 Reinspection 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(WOO)
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penally 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 work�e�rs/,'�c.�om e�nsaattlpn�Insurance carrier and policy number are: 4� / Z Ot"
• Carrier: J /r'f�AT'I'�`'.�/�� Policy Number /10 J Z5 — 2,Cie S
(This section need not be completed it the permit is valued et one hundred dollars($100)or less.)
' 0 1 certify that in the pert• e of the work f• wh' h this permit is issue' I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of : omia,a •agre: at i should become sut to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these pr• 1/•
Applicant Signature: A / aced rLk AF%A 1 Date: ,2- 20-0
WARNING:FAILURE Te-EC - WORKERS'COMP 'SATION COVERA•E IS U •WFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL INES UP TO ONE HUNDRED
THOUSAND COU-ARE(5100,•IN,IN ADDITION TO THE COST OF COMPENSATI•-•,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 licens'd oder•rovisio •f Chapter 9(c-mmencing with Section 7000)of Division 3 of the Business and Professions Code,aripi my Ijcense is in full
force and effect.Lis.It i IClass It • I, 17, a//
Contractors Signature: ' n 1=vi Date: 2-Lo-07'
CONSTRUCTION LENDIN r AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). '
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Ttle 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:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 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 0 N
(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 ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aaEermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No
(Section 65850.2 of the California Government 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? ❑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-des4au
erty for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Si aApantA O Author' d ApIcant CODE t INPF DATE INTTALS CODE( INSPECTION TYPE PAff. EMU
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing Ku
200 Final Re-Roof 210 Final Electrical anti Off{
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
p 9 CITY OF COSTA MESA
4 BUILDING DIVISION
> %
WORKERS'COMPENSATION DECLARATION: -
I hereby affirm under penalty of perjury one of the following declarations: •
„,Fpm. 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.
0 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' Insurance carrier and policy number are: - - ��D.SZ S"/—2 3
-Carrier:er: f"%/f AJ Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that 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 DOLLARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed,ynder rovisions of Chapte 9(commencing with Section 7000)of Division 3 of the Business and Professions C e,and m !icons*?is in full
force and effect.uo.a '}7 7 Sof gyp- _/ Class# 5 '3L Z7 —/e C.
Contractors Signature: tale (/Z/Eu.9l� Date: _ Z '7 b
CONSTRUCTION LENDIN AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I,as owner of the 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)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Drivers License No. _ Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,Califomia Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be 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 Califomia Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aggermit 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 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 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.1 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-des - ed property f. 'nspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
/
S. .. re. Legal Owner(s) pp '�/j Date
/ ( 'el r
AnW rAu orized Applicant Z. Date
CODE I MsPFCTION TYPE WI JNTRIALS CODE II INSPECTION TYPE DM MALI
1616 Fixed System Final Fire Prevention 206 Final Mechanical I ti'OI L
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 •
, Shit CITY OF COSTA MESA -.
BUILDING DIVISION
F ,I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
0 J PERMIT
4 fi+ PO4-00115
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 1128 SEA BLUFF DR Status: ISSUED
Suite No Applied: 02/20/2004
Issued: 02/20/2004
Vicinity:
Parcel Nunmber: 42232211 ISSUED BY:
Applicant: CRAWFORD, SCOTT '
Address: 1306 E.POMONA ,
Phone: 949 855-0180 •
SANTA ANA,CA Zip: 92705
Owner: •CALHOON, RORY D ,
Address 1128 SEABLUFF DR -
Phone: '
COSTA MESA,CA Zip: 92627-4068
Contractor: CRAWFORD CONSTRUCTION ,
Address: 1306 E. POMONA
Phone: 949 855-0180
SANTA ANA,CA Zip: 92705
License: 349757
Arch / Eng : : ' •
Address:
Phone:
Zip:
--- -.--_- --License: - . .
SCOPE OF PERMIT
REF:804-00387.CONSTRUCT 450 SQ.FT.GUNITE POOL&SPA;ADD GAS LINE FOR BBQ. -
. FEE SUMMARY- ,
AMT QTY AMT •• QTY AMT QTY
ISSUE FEE $23.50 .. . Laundry Tub/Washer - $0.00 • 0 . ._ - Sump Pump - $0.00 0
Backflow irrigation $0.00 0 ' Landscape Irrigation $0.00 0 - Swimming Pool $60.75 1
Backflow Preventer $0.00 0 P-Trap , $0.00 0 Trap Primer $0.00 0
Bathtub $0.00 0 • Pressure Regulator $0.00 0 Urinal $0.00 0
Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0
Connect(Ice,Soda,etc) $0.00 0 ' Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0
Dental Units \ $0.00 ' 0 Septic Tank $0.00 0 Wash Basin $0.00 0
Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0
Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0
Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0
Drain, Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0
Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0
Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0
Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work Is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
O I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for bisection 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
C XI 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: S7p?&`y cts Policy Number: - /10612. 57 - 2003
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that 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 DOLLARE($100,C00),IN ADDITION TO THE MST 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 license lip, rovisions of Chapter 9 commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full
force and ers ect.Lic.# 7/f`^eCL Classat : It — -2 y /T/C"
Contractors Signature: l/� Date: 2—2 0 �O
CONSTRUCTION LENDIN 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 tile 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 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)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 6,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 California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aEermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes j�No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
abov cribed prope r inspection pu oses.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Si ure O eget Owner(s) Dale
— Zo -o9
An r A hodzed Applicant Date
CODE I INSPECTION TYPE PAIS INITIALS CODE t INSPECTION TYPE PATE BMW
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing I Z19 4 �L
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition • 250 Final Building/Occupancy
•
CITY OF COSTA MESA
• REFUND REQUEST FORM
From: ❑ Finance Vendor#:
® Building Safety - Permit#: B04-00285
❑ Planning
Amount: $ 97.75
❑ Public Services
❑ Community Services Date: 11102/04
❑ Other
Depart nt Si nature
Account Fund Organization Program Project/Grant Amount
415130 101 18300 20410 $97.75
•
Name and address of applicant: OLSEN ROOFING COMPANY
6951 NEWTON AV
LONG BEACH, CA 90805
Phone: 562-634-8470
`
I 1 J
Y?
Applicant's Signature Date
REASON FOR REFUND:
CUSTOMER CANCELLED ROOFING PROJECT.
lid! $/
APPROVALS:
Finance:
City Manager:
240122 MW ONLINE
d==i•..
Above All A Good Root
OLSEN ROOFING COMPANY State License C-39 254149 • 6951 Newton Avenue
Long Beach, Calif. 90805 • Phone 634-8470 • FAX 634-3841
City of Costa Mesa
Building Division
P. O. Box 1200
77 Fair Drive
Costa Mesa CA 92629-1200
October 25, 2004
Re: Building permit B04-00285
1128 Sea Bluff Drive
Please refund. Permit not used due to cancellation by customer.
Sincerely, ,.
Peter E. Hitchcock °17-1- O I
Superintendent p ,
cov re.r,v
` ,i t CITY OF COSTA MESA r.
4 BUILDING DIVISION '
> •t �� QEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
PERMIT
J B04-00285
(714)754-5273 • Fax(714)754-4856 • www.ci,costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 1128 SEA BLUFF DR Status: ISSUED
Suite: Applied: 02/02/2004
Vicinity: RESIDENCE AND ATTACHED GARAGE Issued: 02/02/2004
Parcel Number: 42232211 Zoning: /
Applicant: HITCHCOCK, PETER ISSUED BY: jest
Address: 6951 NEWTON AV
Phone: (562)634-8470
LONG BEACH,CA Zip: 90805
Owner. CALHOON, RY D • EXTENSION
Address 1128 SEABLUFF DDR
Phone:
- ALLO D
COSTA MESA,CA Zip: 92627-4068
Contractor: OLSEN ROOFING COMPANY PER .0
Address: 6951 NEWTON AV
Phone: (562)634-8470 EXPIRES ���a9j!`/
LONG BEACH,CA
Zip: 90805 License:" 254149
Arch : - • Eng:
Address: Address: .
Phone: Phone:
Zip: License: License:
i•/i / -- SCOPE OF PERMIT
. REROOF RESIDENCE AND ATTACHED GARAGE:T/O.EXISTING CEDAR SHAKE'ROOF,REPAIR/REPLACE SHTG AS NEEDED, 1 LAYER 15#
FELT,APPLY"30-YEAR FIBERGLASS COMP SHINGLES."23 SQUARES
FEE SUMMARY , .
Plan Check: $0.00 --- - - - Calc Valuation: $3,837.00
Permit: $97.25 Claim Valuation: ' $3,837.00
SMIP Res: , $0.50
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $97.75 , __ -
- PLANNING &ZONING
SETBACKS '
MAIN STRUCTURE Front 0-0 Rear - 0-0 . Left 6-0 Right -0-0
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 . Proposed: 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
244648(8/00)
DECLARATIONS "' ( ) x ,
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.
Ihave 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'Jcompen tion In urance carrier and policy number are:
Carrier: S/TI I� ) T
Policy Number: lo.e 2UO
(This section need not be comp/e( d if the permit is valued at one hundred dollars($100)or less.) 1
❑ I certify that in the p: rmance of the work f)r which(¢Is permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation law • •alifornle, nd agrg0���t' sJ/ould become ubject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with thes= i 0 5. I/ 7�llVpA`/�
Applicant Signature: - w _ Date: 7_1_04
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($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 li sadfnd rip ions of Chapter 9(commencing with Section 7000)of Division 3 of the Busineta fessions Code,and my license is In full
force and effect.Lic.N ,4 t Class ft
T,v
Contractors Signature: L _ P6'
Date: 2!2--0t1
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 fore 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 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)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. 0 Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,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? 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 ❑No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No
8 (It"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
'Si e Of e al r(s) 2-7 Date
And/Or Authorized Ap nt Date
ODE II INSPECTION TYPE PEE INTmALS CODE• INSPECTION TYPE On REALS
•
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing ..
200 Final Re-Root 210 Final Electrical
201 Final Block/Retaining 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
p. T
11151 c
IL Above All A Good Roof eG,T0oFCO Or �®
OLSEN ROOFING COMPANY State License C-39 254149 • 6951 Newton Avenue BYO ST OOQ
Long Beach, Calif. 90805 • Phone 634-8470 • FAX 634-3841 ,�
-r
July 1 2004
Ed Petros
Costa Mesa Building Department
• Olsen Roofing Company hereby requests extention of building
permit No. B0400285 for a 6 month period . Owner is very in-
decisive regarding color. and style of shingles.
Thank you,
//Ita.
t-xj
Peter E. Hitchcock
Superintendent