HomeMy WebLinkAbout2833 SHANTAR DR - Building Permits - ' M CITY OF COSTA MESA •
4a...,
BUILDING DIVISION
. •< +,,,' 41 : DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
1. 1 1AAiar l ;
04. PERMIT
E07-00238
imm0ft
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesaELECTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 2833 SHANTAR DR ' Status: ISSUED
Suite No Applied: 03/21/2007
Vicinity: Issued: 03/21/2007
Parcel Nunmber: 13940242
ti
Applicant: HU, MICHAEL I /
Address: 17165 NEWHOPE ST
UNIT J --- Phone: 714;444-2648- ISSUED BY: / LA s.
FOUNTAIN VALLEY• ,CA 1 Zip - 92708 - - v
Owner: WINTERMAN, STANLEY
Address MICHAEL - '',.
,.'COSTA MESA�CA -t: 1 "
2833.SHANTAR DR','. , -- Zip: 92626 '."'":.`...i, - -' - .."--i-`
Contractor. ROVICS CONSTRUCTION INC v��,( ���
Address:- 17165 NEWHOPE ST
• ,r UNIT J ,%�� Phone:. 714-444-2648 ,. .�' `\ �,\\_\
•• FOUNTAIN VALLEY,CA Zip: ' 92708 ,
License:800996 - - v \
®. .
' SCOPE OF-PERMIT ,
' 'KITCHEN REMODEL:WORK INCLUDES:RELOCATE/REPLACE ELECTRICAL,APPLIANCES AND VENT-
REF.: B07=00337 - <� 1.
ELECTRICAL INCLUDES:7 LIGHT FIXTURES AND 5 OUTLETS. \ �,
'
. ' ' - 7 iiir FEE SUMMARY , ,,.:-:
Quantity. ., - Quantity, > , --_- - .
ISSUE FEE 523.50 Temp Dist System/'Lighting , $0.00 0
,Temp service test $0.00 ' Busway/100 ft $0.00 0 '
1`Res.a/c package - $0.00 = _ - _Jr --Standing-Section e.'---- $0.00
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 %
Pooh Spa' $0.00 0 up to,1O kva/kw $0.00 0 V!"
Lighting Fixts " $7.70 - 7 "yup to50 kva/kw $0.00 0i, , _ '
c
Recept Outlets ', $5.50 5 _ -,��yup 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 --10 7 ' '
Res Appl. $0.00 • 0 ..--„,;;114:- Low Volt Wiring System/Ckt $0.00 .7 0
Service to 200a ',$0.00 0 s 't ! •- Misc.Conduit 1$0.006x7 0 ' ;".�,�
Service to 1000a $0.00 0 L -misc.Conductor. � $0.00 0, -' ./ , .
Service over 1000a - '$0.00. ::-.---.1,-- Or'` - -Circus(gen or rideic'''-•.-"'.` $000' 0, ,
Motors to 1 hp - $0.00' 0. - Circus(mech ride or lights) ' - -,$0.00 . v 0 7
Motors to 10hp ' ''50.00--H---, 0 � ' - - .ChristmasTree Stand ,,,...1-',„,$0.00/ 0 at ,
Motors to 50hp Vi- $0:00 0- ='-' -- ;'' Fireworks Stand - ' ->2:2--1''..." $0.00 (/."0 j/
Motors to 100hp $0:00 ,.0--;. - - ---Other Electrical Fee ' $000.' / /�,/
Motors over 100hp ' `' 7$0,00 . 0-'- - - - ' r; ``-:-/-,'.- i '� /
Communication drops ' , $0.00' 7 • -'O ._ '- .' - --'Inves_tigation Fee i' 'N.-,--$000 /�
Sub panel to 200a $0.00` ',' 0?'/ __-t _ Plan Check Fee.;- `, $0.00'.7✓�
Pole Light Pkg $0.00, ' "i0- - ,Reinspection Fee' '` $0.00 ' /
Sign Circuits '$0.00 0 :, -- -�� .-. i'--,
Temp Pwr Pole $0.00._ 0 l., .:-.TOTAL CALCULATED FEES�36:70
Intermed Pole
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.
i
• INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicabl9 odes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiratio 10" his permit.
FOR INSPECTIONS CALL: (714)754-5626
244646(8/00)
DECLARATIONS Ly •
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.
IQ 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: l /���
Carrier: ,z1 7& EN NP Policy Number. Y//_
(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 pr•i 'onsc— /
Applicant Signatu -. a _ _ Date: 3/?77°
D J
WARNING:FAIL •E TO SECURE WORKERS•COMPENSATI• AVERAGE 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 licensed,under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business andfrofessions Code,and my license is In full
force and effect.Lic.# A!/O79 6 Class#
�s
Contractor's Signature Date: t/?//e
?—
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or Improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property,em 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 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,Ttle 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 et 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 end 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 Duality 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 partof 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 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
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 end state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of Legal Owner(s) 2/ ,`,J2 Date
\ And/Or Aut ' ed Applicant / , Date
CODE I INSPECTION TYPE DSIE JArmAl& CODE INSPECTION TYPE DSTE It��
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1268 Pool Spa Final 208 Final Plumbing
t
200 Final Re-Roof 210 Final Electrical NM
201 Final Block/Retaining Well 212 Final Fire Prevention •
202 Final Factory Fire Place 220 Final Planning Approval
,a •
203 Final Signf` 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
FCITY OF COSTA MESA
4 '
BUILDING DIVISION
r %' ' • DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
w.w
l .i i
41 PERMIT M07-00152
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT
Job Address: 2833 SHANTAR DR Status: ISSUED
Suite No Applied: 03/21/2007
Issued: 03/21/2007
Vicinity:
Parcel Number: 13940242 /� )Y�( /.
_ ISSUED BY: / \�
Applicant: HU, MICHAEL - -
Address: 17165 NEWHOPE ST-..'`_: �- -
UNIT J ,-;///, ' Phone: 714-444-2648, -
FOUNTAINVALLEY CA _ . Zip - 92708 , / �-.
, -
Owner ,-WINTERMAN STANLEY _ ,'<� :..!, v
Address , MICHAEL `-
/,COSTA MESA,CA � - Phone: - - �
/ - 2833 SHANTAR-DR '� Zip: 92626 v)A7\
�> - y ) '•7-, / \C.
Contractor ROVICS CONSTRUCTION INC �ANy\,/
, Address: 17165 NEWHOPE ST "i.i.�-7: Z \:
it : .A`.A
UNIT) Phone:: 714-444-2648 -
- FOUNTAIN VALLEY,CA Zip: '92708 i.-��` ' ' ' • ',i.
' 'License:800996
, ' "- SCOPE OF PERMIT' -
' . KITCHEN REMODEL:WOR_K INCLUDES:RELOCATE/REPLACE ELECTRICAL,APPLIANCES AND ,',-
VENT.REF,:-B07-'003$7--
,
EF,:-B07-00337
MECHANICAL INCLUDES: 1 GAS PIPING AND 1 HOOD W/MECH EXHAUST. - -
\"
, ,FEE SUMMARY
Quantity '',..✓:_ J_ .a - - s ' . Quantity, '
ISSUE FEE $23.50 ' - - - Repair/Alt Absorbtion Unit $0.00 - 0
InsFAU<100 k BTU $0.00 0 . Repair/Alt Refrigeration Unit /•'$0.00 .0 , t,
t I
Inst FAU>100 k BTU $0.00 0 _ _ . ,Ventillation System --'1 I$0.00 0:
Repair/Alt Cooling/Heat - $0.00-- '0-_ _ ' /" A.Evaporative Cooler; • /,..
Inst/Rep.Recess Wall'Htr $0.00= 0 - - . Commercial.Incinerator" '';$0:00 0 ',�
Refrig Sys<100 k BTU, $0.00 ' 0 "- - - -Domestic Incinerator ' ,27.,/ $0.00---0 -,l,/ /
Refrig'Sys>100 k BTU $0.00 0 Compressors/Absorption Systems -- i • /
is
Gas Piping' _ $6.15 1 Up to 3:hp/100 k BTU ' ' $0.00,;0'.:'/-
Factory
Factory Fireplace' ' $0.00 0 - 3-To 15 hp/500 k BTU
Hood w/Mech Exhaust - $10.65 1 15 To 30 hp/1,000 k BTU •)$0.00, ,00
VAV Box - $0.00 0 -''t 7 l'-',-4/4 `,-30 To 50 hp/1,750 k BTU k> $0:00 / 0 /
Vent Fan/Single Duct -N-: $0.00 0 - - Over 50 hp/Over 1,750 BTU -/ , ' $0.00 ''0/
Appliance- . - $0.00 0 - - Boiler s'*^',-.. • i �
, /
Fire Dampers -;$0 00 0 ' Up to 3 hp. h. , ", C;'
Smoke Dampers, - $0.00 0.- -3 To 15hp' : -�-' - $0.00,, 0
Inst or Relocate Appl Vent ," r .- $0.00 0 ' ,/ " ' x-.15 to 30 hp, -" $0.00 0
Air Handlers< 10000cfm. „ $0.00. 70 _ • 30 to 50•hp jj/ • -'. n) A$0;00 0
Air Handlers> 10000cfm ,. $0.00- -0 - Over 50 hp -2•., �, = !,- ;$0.00 0
Floor Furnace A v ' N $0.00 0 Other Mechanical Fee \\�'., ) �,' /
Floor or Suspend Heater - .$0.00-, - 0 - Investigation"Fee '`_ - , $0.00 ,
-Plan Check Fees -
/ - Reinspection Fee` VN", ,—' // $0.00
- _ " -' '' - ' ' , TOTAL-CALCULATED FEES $40.30
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 if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
I
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and +
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permi
FOR INSPECTIONS CALL: (714)754-5626
2448-46(6'00)
DECLARATIONS (l
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
...,,,ff( 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'compensation InsuranceIncarrier and policy number are: /
Carrier: %'7#k Fu nPolicy Number: q6-
(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 pr s / 2
Applicant Signatuu O V \r` T Date: NV 2,10 7
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO GRIM PE TIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100.000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed u r provviisions.of Chapter 9(commencing with Section 7000)of Division 3 of the Business and • ofessions Code,and my license is in full
force and effect.Lic.# 0 /9 ✓ Class#
Contractor's Signature:„..5C)1r Date: ®0
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: • Date:
OWNER-BUILDER DECLARATIONS: •
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the properly,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 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SA)ETY 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:
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 ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the Califomia Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No
(Section 65850.2 of the Califomia 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 Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescnbed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If yes•,attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of Legal Owner(s) ate
3/2//
And/Or •. -• zed Applic: ate
161E# Fixed yN TYPDATE fly CODE I INSPEFinal MechanE
ical
W...2
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 Builtling/Occupancy•
434" F CITY OF COSTA MESA
,j .
BUILDING DIVISION
I "Fier I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
**4 11111Ka s•
PERMIT
-"�oommrrcc�o P07-00172
(714) 754-5273 • Fax(714)754-4856 • www.ci.costa-mess
MBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUJob Address: 2833 SHANTAR DR Status: ISSUED
Suite No Applied: 03/21/2007
Issued: 03/21/2007
Vicinity:
Parcel Nunmber: 13940242 • f
Applicant: HU, MICHAEL - - - -- ISSUED BY: t(
Address: 17165 NEWHOPE ST --', - --"
UNIT J c:1,2::-/if ".Phone:, 714-444-2648k
FOUNTAIN.VALLEY,CA - � Zip:.! 92708
-� -_
Owner ,VVINTERMAN STANLEY _"- i 7
Address ,MICHAEL \ - - - ��`�
�! /COSTA MESA,;CAS %"� Phone: ,,- V ,\
/' ' /2833 SHANTAR-DR Zip: 92626 ` - - j
��
Contractor:' ROVICSf-CONSTRUCTION INC �C`k;A ' v v\
' Address: 17165 NEWHOPE ST \ i ', . .-A
•
' UNIT J -, Phone: J714-444-2648 --
' FOUNTAIN VALLEY,CA Zip: -92708 ti--
- `' - License: 800996
�� - - _
' ' ,",,-,<:\•.. - SCOPE OF PERMIT
, " ' KITCHEN REMODEL WORK INCLUDES:RELOCATE/REPLACE ELECTRICAL;APPLIANCES AND VENT.
REF.: B07-00337' A : - .
PLUMBING INCLUDES: 1 DISHWASHER;1-GAS-(1-4 OUTLETS),AND4KITCHEN SINK.
H --0 }'t -- C- y
/�. , - _ .
- - FEE SUMMARY - • --
` AMT QTY - AMT •QTY '• ;, AMT 'QTY
ISSUE FEE $23.50 Laundry-Tub/,Washer $0:00v,,.'0- . Sump Pump -,,$0.00 0
Backflow irrigation $0.00 0 Landscape:lrrigatiori ."-.--:,-$0:00,/10 - Swimming Pool -.:,I . 1: $0,9011 0
Backflow Preventer $0.00 0 - P-Trap _..<-;-,. '- $0.00 /, 0> - - - Trap Primer :11-14,, $0.00 ; 0
Bathtub ' $0.00 0 Pressure Regulator $0.00 0 " Urinal x/'
,/ ' -(10.00,r ,0
Clarifier System .. $0.00 0 Process Piping(per 10 ft) <$0.007 0 1 Vacuum Brkr Bkflowr(1 4)--' $0.00 . t 0
Connect(Ice,Soda;etc) - $0.00 0' Receptors _c_'$0:00 -.=0 Vacuum Brkr Bkflow(5+),." $0.00 / 0
Dental Units $0.00 0 Septic Tank '50.00 0 Wash Basin --17- -;'$0:00,` 0
Dishwasher , $9.80 1 Sewer Cap for Demo , $0.00 ' 0 Wash Basin Set' • , $0.00 0
Drain,Floor , - $0.00 0 , Sewer Connect'..' 50.00 0 Waste and,Vent System 50.00 0
Drain,Rainwater" "$0.00 0 ' Sewer Private Line • ". !00,. 0 Water Closet(Toilet) / ,' 0.0
• $ 0 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,t";°:
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.
lave 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:
g N - .
• Nuini;er l6- I'15 57-
is section need not be completed i1 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 Califomia,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
corn hi/with these provisi•• .
p lcanOignature: -• Date: . fl 0
: AILURE TO SECURE WORKERS'COMPENSATb' COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL NALTIES 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 ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affir I ... ' :mad tu der provisions of Chapter 9(commencing with Section 7000)of Division 1e,8uciness and P fessions Code,and my license is in fulla:r,
V.rr.7yairlt tjat LLlc:#......e-- '1 C Class l }�
-o• - • s Si.,.
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that 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 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.Ttle 6,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 ❑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 eachh business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application akermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ul Yes U No
(Section 65850.2 of the Califomia Govemment Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No
8 (If yes',attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPUANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of Legal Owner(s) ate
Mao G1M ;11.Gant_.
CODEC INSPECTIONTYPt . DAIt • QRIDAL3 CODES IBSPECTION TYPE PAIS INImALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical / p
1266 Pool Spa Final 208 Final Plumbing Oggn0 HIN T
200 Final Re-Roof 210 Final Electrical
201rt.• Final Block/Retaining Wall 212 Final Fire Prevention •
202 Final Factory Fire Place • - 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
.0" CITY OF COSTA MESA
o4 BUILDING DIVISION
,
f • r., I DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER
k .011C41 • PERMIT 07-00337
%fp ,aft
BUI(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ee.tre MG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 2833 SHANTAR DR Status: ISSUED
Suite: Applied: 03/21/2007
Vicinity: Issued: 03/21/2007
Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N
Parcel Number: 13940242 Zoning: R1
•
Applicant: HU, MICHAEL
Address: 17165 NEWHOPE ST / II
UNITJ __ - Phone: _714-444-2648 , . (
FOUNTAIN VALLEY,CA _ -,:f",
- -'Zip:- 92708 . ISSUED BY:
� -
Owner: WINTERMAN STANLEY - - 11 ' :
Address MICHAEL,-..- , '. - \mac
COSTA MESA,CA -
2833SHANTAR qR -'` - - - Zip:- -92626 . / �
Contractor -:",ROVICS CONSTRUCTION-INC ��vv
Address:; /-17165 NEWHOPE ST"-_;----- /-,A\ •
UNITJ - Phone: 714-444-2648 =- r . ,,,� ,,�'- `
i, FOUNTAIN VALLEY,CA * �cY\
i Zip'. 92708://5,1Y/ License: 800996 ��\\/
'Arch : _ - Eng: A . ;"., ,
', t
Address: . . Address: _ _ - '��, '
.' Phone: .- Phone: ,.L, %.
License - ',License: '\
• SCOPE OF PERMIT \ _
• KITCHEN REMODEL.WORK INCLUDES:RELOCATE/REPLACE ELECTRICAL,APPLIANCES AND VENT,REPAIR/REPLACE DRYWALL.I', 1,,
- • FEE SUMMARY
Plan Check: ' $0.00 ' 7 <"' 1- ` '::, „ 1.:-`17`Calc Valuation: $5,500.00,
Permit: - $125.25 _ _ _ - . _ `' _/4-.•-.' - Claim Valuation: .$5,500.00
SMIPRes:,, • $0.55 . • ,- i;. 1 I .
SMIP Com: $0.00 T r,- /
Other• $0.00 . _w _ _ "
Inspection $0.00 / �,�
/' /
Total: �•
� $125.80 �/ ', �; � /�, i
PLANNING &ZONING
SETBACKS- :='='t! - ,2/ ��
,,- % ,
MAIN STRUCTURE Front-_•.0-0 Rear :',;/-0-'0/•-. Left ...20..`0--/r....,,,, Right 0 :0,/ • //,
.. . - • - /
ACCESSORY Front 0-0, Rear 0-0, - "left " 0-0 - `Right'c0-0 /
PARKING \ Existinq " " 0 '
\ Required Or-,YL Proposed= ° 0 ,/i. J-..,--"j,"?./ • ///, j j
v. /-,.. -",..::::"...:ZS..,,,,,,,,.„,' Q • "r -_ --,..c5//1:12" -vA -; V4`i ii
_
r
• NOTICE: The work authorized by this permit shall comply with all applicable handicap access re irements 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 aba n
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must co with all applicable (—
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result`tn expiration of permit.
FOR INSPECTIONS CALL: (714)754-5626
2446413(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 Insurance carrier and policy number are: / /
Carrier: J 78- /
N1) Policy Number: (p- 7 S 7 ?
(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. 7i
Applicant Signatur \\ - Date: pe�
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION VEgAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO GRIMM/,L PENS 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 licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and,,rofessions Code,and my license is in full
force and effect.Lic.# rir 9 G Class#
Contractor's Signature: Date:
•
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: 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 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 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 Wit the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑Yes ❑No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes 0 No
(Section 25533 of the 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 Calif omia 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(Duality Management District or from any other air pollution control district or agency? Li Yes U No
(Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes ❑No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of Legal Owners Date
a. a 2
An Xrr Authorpplicant Date
LODE I INSPECTION TYPE DALE IN'TALS LOGE! INSPECTION TYPE , LATE II(1
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 BlocWRetaining 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 G`377
P_of GA.-11
"1
FENESTRATION — MAXIMUM ALLOWED AREA WORKSHEET WS-4R
Project Title Date
die
FENESTRATION PRODUCTS— NEW CONSTRUCTION- NEW BUILDINGS
Use this table for new building construction to account for total building%of fenestration.
A B C D E F AV G
4/Type/Pos. Total Total Fenestration Total Percent of ff Total%of
(Front, Left, Orientation Fenestration, for N,S, E CFA West Facing Fenestration'
Rear, Right, West Facing Orientations Area (ft') Fenestration' Including West
Skylight) Area(Fr) (ft') (C/E)x 1006-4 (DIE)x 100%+ F
( North
South /
East 7`
West f
Totals A9
I) If west facing area exceeds 5%of CFA in climate zones 2;4,and 7-15,the p5 formance approach must be used.
2) If total percent of fenestration exceeds 20%including West facing orientations then performance approach must be used. West
facing area includes skylights tilted to the west or tilted in any direction wherythe pitch is less than 1:12 for Package D only.
FENESTRATION PRODUCTS— NEW CONSTRUCTION ADDITIONS
I ❑Less than 100 ft2, 0 Less than or Equal to 1000 ft2, 0 Greater 1000 ft2
A B C D JE F G H
f Total%of
#IType/Pos. Addition's Fenestration Total Area Total%of Fenestratio
(Front, Left, Orientation Addition's New Area Removed to
Fenestration West Facing n'
Rear, Right, N,S. E,W CFA' Fenestration f make way for (D+E) Fenestration
Skylight) Area(fty Addition (ft) (F/C)x100% (F/C)x100
North B,
South
East
West' //
7 Total
1)Additions that add less than 50ft'of fenestration area are exempt from the maximum total area limits. See Table 8-2 in RM.
2) If the addition has a floor area equal to or less than 1,000 ft',the maximum allowed fenestration%may be increased to by the
amount of glazing removed in the wall that separates the addition from the existing house.See Table 8-2 in RM.
3) If the addition has a floor area greater than to 1,000 ft',must meet Package D requirements. See Table 8-2 in RM.
4) West facing area includes skylights tilted to the west or tilted in any direction when the pitch is less than 1:12 for Package D.
FENESTRATION PRODUCTS: ALTERATIONS
Use this table for alterations to antexisti g building where fenestrations products(windows)are being removed and/or added.
A B /sting
C D E F G H I
Removed Proposed Proposed Total Net Total %of
Existing Removed Installed Fenestration Fenestration
C FA Area Area Installed
OrientationOrientation New Area (ft2) H/A
(ft2) (ft_) Orientation (ft2) (C-E+G) Max of 20%
North/ North _ North
SoutW South South
E East East
st West West L
Total Total Total
1)When 50 or more of fenestration area is added to an existing building,then the fenestration must meet the requirements of
Paclage D e area requirement for the total fenestration area for the whole building, including the added fenestration, must not
exceed 209 °otherwise the Performance Approach must be used. Note:The 5%west facing limit is exempt. See Section 8.3.3 in
the RM for further details.
Res idemia!Compliance Forms April 2005
r
S�Ip ENAgIA�'L°K1TCH.ELV LI_GHTIN(; WORKSHEET-4 WS-5R
Project Title Date
S 1 � /� nl J�
—e 33 �/Z//o �
At least 50%of the total rated wattageagof permanently installed luminaires in the kitchen must be in luminaires that are high
efficacy luminaires as defined in Table 150-C. Luminaires that are not high efficacy must be switched separately.
Kitchen Lighting Schedule. Provide the following information for all luminaires to be installed in kitchens.
Luminaire Type High Efficacy? Watts x Quantity = High Efficacy Watts or Other Watts
w' pC. ON; Yes ty Noo 26 x '9- _ / f'2 or
Yeso No❑ x = or
Yeso Noo x = or
Yes❑ Noo x = or
Yeso No❑ x = or
Total: A: If 2— B:
COMPLIES IFA >B YesNoo
Rules for Determining Residential Kitchen Luminaire Wattage
Screw Base Sockets §130(c) 1
(Not containing permanently installed ballasts) The maximum relamping rated wattage of the luminaire,as listed on a
permanent factory-installed label(luminaire wattage is not based on type or wattage of lamp that is used).
Permanently or Remotely Installed Ballasts§130(c)2
The operating input wattage of the rated lamp/ballast combination based on values published in manufacturer's catalogs
based on independent testing lab reports.
Line Voltage Track Lighting (90 through 480 volts)§130(c) 3
1. Volt-ampere(VA)rating of the branch circuit(s)feeding the tracks; or
2. The higher of
• The wattage (or VA)rating of an approved integral current limiter controlling the track system or
• 15 watts per linear foot of the track; or
3. The higher of
• 45 W per linear foot of the track or
• The total wattage of all of the luminaires included in the system.
Low Voltage Track Lighting(less than 90 volts)§130(c)4
Rated wattage of the transformer feeding the system, as shown on a permanent factory-installed label
Other Lighting§130(c)5
(Lighting systems that are not addressed in §130(c) 1-4)The maximum rated wattage,or operating input wattage of the
system, listed on a permanent factory installed label,or published in manufacturer's catalogs, based on independent testing
lab reports.
EXAMPLE
RESIDENTIAL KITCHEN LIGHTING WORKSHEET WS-5R
rnral,a
Project Title Date
Kitchen Lighting Schedule. Provide the following information for all luminaires to be installed in kitchens.
High Efficacy
Luminaire Type (y/n) Watts x Quantity = High Efficacy Watts or Other Watts
CFL-I Yes 26 x 5 = 130 ar
MR-16 No 55 x 2 = or 110
x = or
X = or
X = or
Total: A: 130 B: 110
COMPLIES IFA >B Yes El No D
Residential Compliance Forms April 2005
rl
- MANDATORY MEASURES SUMMARY: RESIDENTIAL (Page 1 of 2) MF-1R
Project Title Date r,
Note: Low-rise residential buildings subject to the Standards must contain these measures regardless of the compliance approach used
More stringent compliance requirements from the Certificate of Compliance supersede the items marked with an asterisk(Albelow.
When this checklist is incorporated into the permit documents.the features noted shall be considered by all parties as minim m
�
component performance specifications For the mandatory measures whether they are shown elsewhere in the docu�'orf
on this
checklist only.
Instructions: Check or initial applicable boxes when completed or check NA if not applicable.
DESCRIPTIONI. / Enforce
;11:4A Designer -menf
Building Envelope Measures:/ ✓ ✓ I
• §150(a): Minimum R-19 in wood frame ceiling insulation or equivalent U-factor in metal frame ceiling ` , 0
0 0
§150(b): Loose fill insulation manufacturer's labeled R-Value: er 0 0 0
• §I 50(c): Minimum R-13 wall insulation in wood framed walls or equivalent U-factor in metal frame walls(does not apply ❑ ❑ ❑
to exterior mass walls,. .440
• §1501dI: Minimum K-13 raised floor insulation in framed floors or equivalent U-factor. ❑ 0 0
§150(e): Installation of Fireplaces,Decorative Gas Appliances and Gas Logs.
I Masonry and factory-built fireplaces have:
a.closeable metal or glass door covering the entire opening of the firebox, 0 0 0
b.outside air intake with damper and control.flue damper and control / 0 0 0
2.No continuous burning gas pilot lights allowed. 0 0 0
§I5th f): Air retarding wrap installed to comply with*151 meets requi em nts specified in the ACM Residential Manual. 0 0 0
150(8).Vapor barriers mandatory in Climate Zones 14 and 16 only 0 0 0
§1500):Slab edge insulation-water absorption rate for the insulation material alone without facings no greater than .. ❑ 0 0
0.3%.water vapor permeance rate no greater than.Y..0 perm/inch
§1 IS' Insulation specified or installed meets insulation �installation quality standards Indicate type and include CF-6R ❑ ❑ 0
Form: _
M.,/
§I 16-17: Fenestration Products,Exterior Doors,and InGltration/E.Iiltration Controls.
6tpnI.Doors and windows between condnioned;and unconditioned spaces designed to limit air leakage. 0 0 0
2 Fenestration products(except lield lab Ir catedl have label with certified U-factor.certified Solar Heat Gain0 0 0
Coefficient IS UGC).and mfiltrannn cemficannn
3.Exterior doors and windows we t�stripped.all joints and penetrations caulked and sealed. 0 0 0
Space Conditioning,Water HAtivng and Plumbing System Measures:
§11044113: In/AC equipment_waver heaters.showerheads and faucets certified by the Energy Commission. 0 0 0
§i Y2)(11): Heating and/or cool ngdoads calculated in accordance with ASHRA E.SMACNA or ACCA. 0 0 0
§1500): Setback thermostalpn ll applicable heating and/or cooling systems_ ❑❑ ❑
/. a
§1I00): Water system-pipe and tank insulation and cooling systems line insulation. ❑ 0 0
I Storage gas water heaters rated with an Energy Factor less than 0 58 must be externally wrapped with insulation ❑ 0 0
haying an instfled'thermal resistance of R-12 or greater.
2 Back-up tarpkrs.fm solar system,unfired storage tanks,or other indirect hot water tanks have R-12 external insulation or ❑
0 0
R-16 internal insulation and indicated on the exterior of the tank showing the R-value.
3 The foll6wi g piping is insulated according to Table 150-A/B or Equation 150-A Insulation Thickness:
.,..fist 5 feet of hot and cold water pipes closest to water heater tank,non-recirculating systems,and entire length ❑ ❑ 0
ofncirculatmg sections of hot water pipes shall be insulated to rabic 1508.
.;vs Cooling system piping(suction.chilled water,or brine lines).piping insulated between heating source and 0 ❑ ❑
��'` indirect hot water tank shall he insulated to Table ISO-B and Equation 150-A.
'4:Yleam hydronic heating systems or hot water systems>15 psi,meet requirements of Table C3-A. 0 0 0
Res dential Compliance Forms April 2005
. MANDATORY MEASURES SUMMARY: RESIDENTIAL (Page 2of2) MF-IRD
Space Conditioning,Water Heating and Plumbing System Measures: (continued) Ctorce-
NA, Designer mens -
5. Insulation must he protected from damage.including that due to sunlight,moisture,equipment maintenance,and wind. 0...-.5 ❑ 0
6.Insulation for chilled water piping and refrigerant suction piping includes a vapor retardant or is enclosed entirely in �(,J ❑ ❑
conditioned space
7.Solar water-heating systems/collectors are certified by the Solar Rating and Certification Corporation ..././.....- ❑ ❑ ❑
• §150(m): Ducts and Fans X�
I.All ducts and plenums installed-sealed and insulated to meet the requirement of the CMC Sections 601, 602:603.604.605
and Standard 6-5;supply-air and return-air ducts and plenums are insulated to a minimum installed levee-R-4.2 or enclosed
entirely in conditioned space.Openings shall be scaled with mastic,tape or other duct-closure system'that meets the applicable 0 CI 0
requirements of UL 181.UL 181 A.or UL I81 B or aerosol sealant that meets the requirementsof UL 723. If mastic or tape is
used to seal openings greater than 1/4 inch.the combination of mastic and either mesh or taQe"shall he used.
2.Building cavities.support platforms for air handlers,and plenums defined or cor�stite ed with materials other than
sealed sheet metal.duct board or flexible duct shall not be used for conveying-conditioned air. Building cavities and ❑ ❑ CIsupport platforms may contain ducts.Ducts installed in cavities and supporrf:platforms shall not be compressed to cause
reductions in the cross-sectional area of the ducts. /r
—
3.Joints and seams ofduct systems and their components shall not bc,ealed with cloth back rubber adhesive duct tapes ❑ ❑ ❑
unless such tape is used in combination with mastic and draw bands.
4,Exhaust tan systems have hack Bran or automatic dampers,/ 0 CI 0 I
5.Gravity ventilating systems serving conditioned space either automatic or readily accessible.manually operated ❑ ❑ ❑
dampers.
6,Protection of Insulation.Insulation shall be protected from damage,including that due to sunlight.moisture.equipment
maintenance.and wind.Cellular foam insular shall be protected as above or painted with a coating that is water 0 0 0
retardant and provides shielding from solarradiation that can cause degradation of the material.
7.Flexible ducts cannot have porous innnpe res. 0 ❑ 0
*114: Pool and Spa Heating Systerd Equipment.
I.A thermal efficiency that com(alies with the Appliance Efficiency Regulations.on-off switch mounted outside of the ❑ ❑ ❑
heater.weatherproof ope ritg instructions.no electric resistance heating and no pilot light.
2.System is installed 5w .
a.at least 36 )Sipe between filter and heater for future solar heating 0 0 0
b.cover f utdoor pools or outdoor spas 0 0 0
3 Pool sv has directional inlets and a circulation pump time switch. 0 0 0
*115 tired tan-type central furnaces.pool heaters.spa heaters or household cooking appliances have no continuously ❑ ❑ ❑
burn pilot light. (Exception'Non-electrical cooking appliances with pilot< 150 Btu/hrl _
§1 18(i): Cool Roof material meets specified criteria 0 0 0
Residentiallligh'ting;_Measures: /
4 $100(kll'HIGH EFFICACY LUMINAIRES OTHER THAN OUTDOOR HID contain only high efficacy lamps as
outlined in Table ISO-C,and do not contain a medium screw base socket 1 E24/E26l Ballast far lamps 13 wails or greater 0 0 0
are electronic and have an output frequency no less than 20 kHz
§t50(k011 HIGH EFFICACY LUMINAIRES•OUTDOOR HID•contain only highetficacy lamps as outlined in Tablein ❑ ❑
I50-C. luminaire has factory installed HID ballast
1501k)2:Permanently installed luminaires in kitchens shall be high efficacy luminaires.Up to 50 percent of the wattage.as
determined in§ 130(c).of permanently installed luminaires in kitchens may be in luminaires that are not high efficacy ❑ ril ❑
luminaires,provided that these luminaires are controlled by switches separate from those controlling the high efficacy
luminaires. -
§I S0(k)3: Permanently installed luminaires in bathrooms,garages.laundry rooms utility rooms shall be high efficacy
luminaires.OR are controlled by an occupant,gensor(s)certified to comply with Section 1191d)that does not tum on ® 0 0
automatically or have an always on option.
§1301k)4:Permanently installed luminaires located other than in kitchens.bathrooms.garages.laundry rooms,and utility
rooms shall he high efficacy luminaires(except closets less than 70H"):OR arc controlled by a dimmer switch OR are ❑ ❑
controlled by an occupant sensor that complies with Section 119(d)that does not turn on automatically or have an always El
on option.
§li0(k)5:Luminaires that are recessed into insulated ceilings are approved for zero clearance insulation cover(IC)and are ❑ ❑
certified airtight to ASTM E283 and labeled as air tight(AT)to less than 2.0 CFM at 75 Pascals.
§1301k 6: Luminaires providing outdoor lighting and permanently mounted to a residential building or to other buildings on
tie same lot shall be high efficacy luminaires(not including lighting around swimming pools/water features or other ® ❑ ❑
Article 680 locations)OR are controlled by occupant sensors with integral photo control cervi lied to comply with Section
1191d). •
*130007:Lighting for parking lots for 8 or more vehicles shall have lighting that complies with Sec. 130, 132.and 147. ® ❑ ❑
Lighting for parking garages for 8 or more vehicles shall have lighting that complies with Sec. 130. 131_and 146.
§1 ill(k)8: Permanently installed lighting in the enclosed.noon-dwelling spaces of low-rise residential buildings with four or
rare dwelling units shall be high efficacy luminaires OR are controlled by occupant sensors)certified to comply with IS 0 0
S:ction 119(d).
Residential Compliance Forms April 2005
— X / �__ Iz/J&(o
�� Signed Date
,—� -t 1ft I have reviewed and understand Nis Final Drawing
O �1 with my HOMB OEPOi�Oesigner. i
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All dimensions aim dcsisnmions given 33oA� Thiel is an original design and must not be Deigned: L/302006
subject to verification on jab site and L..' released or copied units*applicable fee has Printed' t Via/]ooc
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.
4111 CITY OF COSTA MESA
4 BUILDING DIVISION
> I p;, E.
DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
4. PERMIT
,y,lin • B01-00009
%axon se
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.c_kus DING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
• Job Address: 2833 SHANTAR DR U Status: ISSUED
Suite: Applied: 01/03/2001
Vicinity: RESIDENCE&ATTACHED GARAGE Issued: 01/03/2001
Parcel Number: 13940242 .Zoning: R1 R1
Applicant: DICKERSON, RYAN ISSUED BY: ..."4Y-
Address: 15201 PIPELINE LN#A
Phone: (714)936-5908
HUNTINGTON BEACH,CA Zip: 92649
Owner: WINTERMAN, STANLEY
Address MICHAEL
COSTA MESA, CA Phone:
2833 SHANTAR DR Zip: 92626
Contractor: CONSUMER SERVICES
Address: 15201 PIPELINE LN#A
Phone: (714)936-5908
HUNTINGTON BEACH, CA
Zip: 92649 License: 676090
Arch : - Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF:T/O EXISTING ROOF,25 FT OF 7/16 OSB, 1 LAYER 30#FELT,APPLY"OWENS CORNING"40-YEAR COMP
SHINGLES. 2500 SO FT
• FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $6,000.00
Permit: • $125.25 Claim Valuation: $6,000.00
SMIP Res: $0.60
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $125.85 -
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
244646(6/00)
DECLARATIONS
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 by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
E I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed it the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Califomia,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. //�l
•
Applicant Signature: Q N Date: ) 4 4.4WARNING:FAILURE TO SECURE RICERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI 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 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#
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).
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).):
O I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to en 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.-properly tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,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 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,ore 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 0 N
(Section 25534 of the California Health and Safety Code provides that the Costd 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 ❑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? 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? ❑Yes ❑No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
ignature Of}ggat.9wner(s) Da
( c //3 QY
d/Or Authorized Applicant ate
CODE I INSPECTION TYPE EatTE INTRIALS QODEI JNSPFCTION TYPE PATE MEL9
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof /_t� of 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
owNER PACESETTER WEST 'INT VENTURE DATE OCT 2 3 1952
JOB ADDRESS 2833 Shsyitr- Dr BUILDING PERMIT NO.17942
GENERAL CONTRACTOR Andros Land Co. VALUE $20,112.00
AP No139-402-42 LOT 90 TRACT 4349 FIRE ZONE DESCRIPTION OF WORK Res.w/att.gar.
INSPECTIONS Signature DATE GROUP I&J TYPE V ZONER-1
Soil4,Af //-Cy,z PERMITS ISSUED
Gas M./1 _ SUBCONTRACTOR ir-ileDATE NUMBER
Water !r0
Rough Com. Refrig. 0 Air Cond. ❑ _ —/
Rough Heating Ari -• y. .�/�.7. "_/�-�7T/CA. /p_ A ,
Rough Plumbing - .� /r/i�.��, �.,t'1 7r�i7R'�." .//_--/-/v' - A-]O/e, ✓ /'
Miscellaneous -'✓ _
Prop.Swr.Line,[-]-House Con. 2-St"Swr. ❑ ave �4-}sFLUME C_QNT NOV 2_ re . '
Sprinkling System -'
tY
Construction Pole
Underground D Power D _
Rough Wiring /Y/ /-7-C ,�- oma. 7)-} 7-G.7%="?
Trenches ❑ Forms ❑ Steel Reinf. D fi-.1'1 /l-)'7i
Floor System Fj-a+ `�
Bond Beam 0 Steel Reinforce 0
r
Sheathing ni_b.-jJ-41--
Frame and Flashing 11 1,-4-1-6%
Lathing — In-' - Out Pia u l-`/ 741�ki_J-L/-('S I.,..1 y-(.'7i
Plaster, brown coat 2-2'x'3
Refrig. 0 Air Cond. 0 Final
Heating, Final a .:1-2/20
Ylumbing Fixtures, Final / _ Si...e..--1
7
Final Gas TestElectric Fixtures, Final P 6 0
Building, Final fl 2? ' ?-91- (3
OCCUPANCY
FORM BU4.5M — 7-61 17942
17942 FE REGERVED
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX SIT COSTA MESA.'CALIFORNIA • y OCT 1 1962
F For Applicant to Fill In Completely I\ FINANCE DEPT.
PP P Y APPLICATIQ�YFO�R VVQIF1 I�FSA
• TYPE OR PRINT .
LBUILDING
AUDDNG - -t? J hi/mit-4g.
.--
' ///����Yjj CO
LS
.T
-A
MESA. CALIFORNIAFor
/ yam. For Office Use Only
GWN PrecO r„yrs 41ST J / 1 E' '7 I RECEIPT NO. PERMIT NO.
MAIL // C /A/ 4 J/)�l A/ V`-`-' RECEIVE BY I O/(J'E_iEIEIVF�O� Fr .`I,SS�UEOY.
ADDRESS
^_``p �,�✓� �l/,J `H �J T3 E3SIV S �-�t.je /�Ry /A�-'
CITY c-{��,tF /liJ ii TI•EI,d�.i 9a3�iS ADDRESS OI�3rY (;�Lfullti I�/N•
ARCHITECT /
OR ENGINEER JiA_� /SA-�rLfT TEL. COSTA MESA. CALIFORNIA
NFIRE .
V ,J l^1 '
ADDRESS �A7//J-fr/(J--��/'--%��'�(��/✓/ /� ZONE TYPE GROUP( /
CONTRACTOR),, -'tJpgz S /-./44J.Q A61 . APPROVED DATE •
ADDRESS /6 C3 A4h,I/aet. 1- ZONING
IZONH / NO.OF USE OF NEW3/4.. Zs fill
_ CITY `/ (�/�� L,Jr/�345
�� PLANE �/� BUILDING)(,� ,fcan r�o
LIC.NO. �`J [ (A N0.// / (f -� DESCRIPTION �J ''7O �( f ft /
SIZE /!!! •J�J /�/� NO. OF BLOCS. p 'J
OF LOT ` D x �L/ L� NOW ON LOT A.P.NO. /3( — VO a — 7 ,
' USE OF
EXISTING BLDG. / / / YARDS EVES
- - I APPROVED ALLOWED
' SETBACK LINE FROM �^ I (CENTER LINE ST.)
CENTER OF STREET —J 7 REAR YARD % FRONT •. 7 FT. IN.
SIDE YARD I LEFT I RIGHT R.SIDE 6 FT. ------ IN.
DESCRIPTION OF WORK .---L.SIDE �FT. N.
NEW I "VII ALTERATION I II ADDITION I REAR 'J%3 �_
FT. IN.
REPAIR I I MOVING I II DEMOLISH I APPROVED e.,)-40
/� DATE 71 7TJr�
BUILDING 11 NO. OF l-Y �m,
SIZE /.SSI%,/(�'/!J//� ROOMS �,[S[T�O(RIES�EXTERIOR -Y
COVERING WGr/v[/G(/ I RCOWERING ��./�`T �
124/ U -- /< WO_ R OEED
SA P' _ /A74a - ° ,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
THE AMOUNT SHOWN UNDER A PE T IF FOR THE
AND STATE THAT THE OL IS CORRECT D AGREE TIJ COM- PURPOSE OP ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL C TY ORD( CES AND LAWS RE ULATING
BUILDING C/./D �'•�,o/ ^ VALUATION
SIGNATU PERMIT FEE $ � . ..-”)Je/� �/ ‘6�'7 N
PERMITT + T///���j $ a ,, //a-° PLAN CHECK $ 3 3- w'
AUTHO- "E, , . .C�, Le(L/�! ' `��LCa"' p Q d-O c
...... TOTAL FEE $ / /i 0