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HomeMy WebLinkAbout2245 SANTA ANA AVE - Building Permits r . 1 t`,5ttit9 GITY OF COSTA MESA BUILDING DIVISION . >y,,,,- ,r a DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER �rv�a► PERMIT "4. ar 4.�mso.4. E06-00444 (714)754-5273 • Fax(714)754-4856 • www.ci.costa•mesa fTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2245 SANTA ANA AV Status: ISSUED Suite No Applied: 05/09/2006 Vicinity: Issued: 05/09/2006 Parcel Nunmber: 42608209 Applicant: HANOLD, GEORGE j Address: PO BOX 2871 ' Phone: 949-929-8686 ISSUED BY: COSTA MESA,CA Zip 92628 Owner: SCIENTIFIC THERMOGRAPHY CTR Address 2245 SANTA ANA AVE FX ED COSTA MESA,CA Phone: 92627-1832 �++�� • • DATE L• ; i►; Contractor: OWNER-BUILDER Address: Phone: Zip: License:000000 • SCOPE OF PERMIT DEMOLISH EXISTING 707 S.F.S.F.D.CAP ELECTRICAL AND SEWER. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting ' $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0 Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 Switches $0.00 0 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 ` Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 / Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 • Motors to l0hp $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 $9.80 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $33.30 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2448-48(8/00) • 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 Insu . ce carrier and policy number are: Carrer. Policy Number: (This action need not be•• •a,.Il t .permit Is valued at one hundred dollars($100)or less.) i _ I-certify that in di' . :n e • he work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' —compensah th l: :d. ':,:nd agree that If should become subject to the workers'compensation provisionsectipn 37,N of the Labor Code, shall forthwith complywithto I : ..,v".io •-. //G Applicant Signature Ddtd:'� IWARNING:'FAILURE • • R • ORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE($1•OR,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: 1 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 N 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: r 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 subjra the applicant to a civil penalty of not more than five hundred dollars($500).): i -IOC 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 - t e pr.'arty,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code: co ra' •s 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 .ursu nt o e Contractors License Laws.). ❑ I am . emp ,sec. Business and Professions Code for this reason: / - rignature: '' - ii . �/ Dires:_ 7`'r� . Verification of• nershi.by(type of document,i.e.-properly 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 Wit the applicant or present or future building occupant need to file end 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). _ t 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 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 st 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 application akgermit 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). 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). • -77If a permit from the South Coast Air Quality Management District or other air pollution control distrj or agency is required for the work which is the subject of this • application,have all of the disclosures prescribed by Califomla 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 , .-• OR • • ' 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 s e la,s an. ci• .rdinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the , above-described property for insp: tion p.rpos•s. •ree not to occupy or allow occupancy of any building authorized by this permit until final inspection. •Ign: 'O f .ga •wner(s) D7Ge/�/1� /.•utho i ed Applicant r 3{ `� CODE• INSPECTION TYPE ' QATI • INTRIALS CODE• INSPECTION TYPE PATI I$TITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical • 1266 Pool Spa Final 208 Final Plumbing / "- ' 200 Final Re-Roof 210 Final Electrical al da 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 a 4 `p5�ft4 CITY OF COSTA MESA 4 BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER etionria• PERMIT 606-00706 %sonmm`e (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.®UiLDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2245 SANTA ANA AV Status: ISSUED Suite: Applied: 05/09/2006 Vicinity: Issued: 05/09/2006 Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N Parcel Number: 42608209 Zoning: • Applicant: HANOLD, GEORGE Address: PO BOX 2871 Phone: 949-929-8686 ISSUED BY: COSTA MESA,CA Zip: 92628 Owner SCIENTIFIC THERMOGRAPHY CTR Address 2245 SANTA ANA AVE ^� Phone: y_ COSTA MESA,CA Zip: 92627-1832 tip Contractor: OWNER-BUILDER I '1 Address: gyp' ' '1 Phone: Zip: License: 000000 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SC • to 'ERMIT DEMOLISH EXISTING 707 S.F.S.F.D.CAP ELECTRICAL AND S. -/ APPLICANT WILL CONTACT A.Q.M.D.PRIOR TO DEMOLITION r111 - ' UMMARY Plan Check: $0.00 Calc Valuation: $11,000.00 Permit: $195.25 Claim Valuation: 611,000.00 SMTP Res: $1.10 SMTP Com: $0.00 Other: $0.00 • Inspection: $0.00 Total: $196.35 PLANNING &ZONING SETBACKS MAIN STRUCT RE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 244E-48(aroo/ ro DECLARATIONS II J a WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: - • • ❑ I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. ❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carder: - Polity Number: (This iron need not be c• plate•if pa it is valued at one hundred dollars($f00)or less.) 70- "'certify that in the •erform: th ork for which this permit Is issued,I shall not employ any person in any manner so as to becom subject to the workers' compensation I: s of C. •• i a gree that if I should become subject to the workers'compensation provisions of Section 00 the Labor Code,I shall forthwith comply with ih• eprov�/:'� L,f/ Q Applicant Signature: '- ./ flDate:.. WARNING:FAILURE T.---AV- W E .COMPENSATION COVERAGE IS UNLAWFUL AND SHAM SUBJECT AN EMPLOYER.TO CRIMINAL E TIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100, ,IN ADDR TO THE COST OFCOMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OFTHE 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# 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 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 d 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 subjec a 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 co elation,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 o a .rope y -m EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORSIo construct the project(Sec.7044,Business and Professions Code:The..n r. tors i•.nse 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 pu•-ua t. r/ntractors License Laws.). ❑ I am exe pt d.r Business and Professions Code for this reason: r -Signature: ./ [- — CExoires._ NW . tiyVerification of 0 nershiproperty ) t� p.y(type of document,i.e.- tax bill or deed): an 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 hes 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 tile 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 apermit tor such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency? 0 Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed Under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 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 A • OR '110- 0 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 stat: aws an. city •rd'%-nces relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspecti• purpos> ,I :•r:•not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sign tura• yewe•n: (s) !/D / .1 .} // ;ODE i INSPECTION TYPE PAIS— INTRIAlE COMP INSPECTION TYPE PATE INITIAL& 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final _ 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall _ 212 Final Fire Prevention 202 Final Factory Fire Place _ , 220 Final Planning Approval 203 Final Sign _ 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 05/09/2006 03:34 62691530 HAFEZI PAGE 02 FROM :CITY OF COSTR MESA FAX NO. :714 754 4856 May. 09 2006 02:20PM P3 • DECLARATION OF AUTHORITY Bldg. PermitIf FOR AGENTS OF PROPERTY OWNER TO APPLY FOR PERMITS This Penult ft Street Address: 2245 SANTA MA AVE —_ AP Number. t I(we) SCIENTIFIC THERMOGRAPHY CENTER • declare that I am the Owner of Title of the above referenced real property,end that I(we)hereby authorize: '" Name: HANOLD PROPERTIES Telephone Number949-929-8686 Street Address: 1941 RAI.RARTC 11R • City: COSTA MESA _ State: CA Zip: 92626 to obtain permits In my behalf,as owner/builder,for at the above referenced property. 2. Should any person become an employs.engaged in the improvement of the property.I (we)shall immediately provide Workers Compensation Insurance coverage and cause a certificate of chat coverage to be filed with the Building Division of the City of Costa Mesa,as required by State of California laws. 3. As owner/builder In fact, I understand and accept that my responsibilities do not transfer to any other person, company or corporation, 4. I agree to indemnify and hold the City of Costa Mesa and Its employees or officers harmless from any claim resulting In damage or personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa. 5. I declare under the penalty of penury that the foregoing is true and correct. , Executed this 09 day or MAY _ 20Q6_,at WEST COVTNA ,California. Print Name: K DOROTHY AALAM Signature: I\t—C--- 0rEtr _ Date: )( 05/09/2006 — -• Note: This a tibrizetlon does not grant authorization b perform the work as owner, it solely provides for t6need power.of atlornay to swan this permit in any bohaa, • • • mom!U.../¶ of . t p•TIl L4 9 CITY OF COSTA MESA • a OlbBUILDING DIVISION > •N-' , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 1. 1 ..r I t f • PERMIT ,•60 P06-00342 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 2245 SANTA ANA AV Status: ISSUED Suite No Applied: 05/09/2006 Issued: 05/09/2006 Vicinity: Parcel Nunmber: 42608209 / Applicant: HANOLD, GEORGE ISSUED BY: 1 Address: PO BOX 2871 Phone: 949-929-8686 COSTA MESA,CA Zip: 92628 EXPIRE Owner: SCIENTIFIC THERMOGRAPHY CTR iP jlw , Address 2245 SANTA ANA AVE I Jr . Phone: DA's' / COSTA MESA,CA Zip: 92627-1832 Contractor: OWNER-BUILDER Address: Phone: Zip: License: 000000 SCOPE OF PERMIT DEMOLISH EXISTING 707 S.F.S.F.D.CAP ELECTRICAL AND SEWER. 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 $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub. $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 v Dishwasher $0.00 0 Sewer Cap for Demo $9.80 1 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 Gas(1-4 outlets) $0.00 0 Sink,kitchen $0.00 0 Water Softener $0.00 0 Gas(Over 4 outlets) $0.00 0 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 0 REINSPECTION • $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $33.30 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it 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)7545626 2446-46(WOO) I • r 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 • ranee carrier and policy number are: Carder: - Policy Number: (This s ' n need not be•• • : ,d if the pe •it is valued at one hundred dollars($100)or less.) - I certify that in parlor nc of he ork for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' L /compensation I: • /for le n• •gree that If I should become subject to the workers'compensation provisions of Se ion 3 0 of the Labor Code,I shall forthwith comply with th• • • .ion•. Applicant Signature: r Date: --Sr 9ec (WARNING:-FAILURE T• • i' ER' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO'CRIMINAL P NALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,•••,IN vrDITI I 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,and my license Is in full force end effect.Lic.it Class P 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 cit 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 si ed 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 Busine 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 is 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. 45-i- 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 on ear 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 ow of th prop ,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code: e cont ctor ense Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with •contractor(s) licen pursue to ontractors License Laws.). ❑ I err exempt e . Business and Professions Code for this reason: •. a r Signature_'- Expires: - - f/1" Verification of Ownersh" by(type of document,i.e.-property tax bill or deed):1 &`-�- Gs- 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: 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,ora 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 C 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 ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 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? ❑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 COMPUANC D O- • ON 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 wi all state aws : • • y ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property inspectio pu •• -:II agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. II Si : r tat Owner(s) /Dale/' ,f r-- di.. •uth•rized Applicant 9 a-u lc ODE I INSPECTION TYPE Pig (NimAL$ CODE! INSPECTION TYPE PATE KOMs 1616 Fixed System Final Fire Prevention • 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval • 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy