HomeMy WebLinkAbout1052 SPINNAKER RUN - Building Permits IWA
GINEERS
17390 BrookhurstStreet,Suite100
?ccWuA#6144(05' / Fountain Valley,California 92708
•
(714)968-1221 •FAX(714)968-9286
(5441
May 11, 1990 J.N. 207-03
City of Costa Mesa
Building Department
77 Fair Drive
Costa Mesa, Ca. 92628
Attn: Mr. Victor Clift
Subject: Fine Grade Certificate
I hereby certify that the fine grading for lots 12 through 20, 22
and 23 of Tract 13224 were graded as shown on the approved precise
grading plans for said project.
-rry Wood R.C.E. 32636
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INSULATION CERTIFICATION �)..
This is to certify that, in conformance with the current energy regulations (California Adminis- �!'"
native Code, Title 25, State of California') and approved plans, insulation has been installed in
the building located at:
f;
Costa MesaOrange
Cal — — County --
4 1052 Spinnaker Run 14 % '
-_),, Stint Mo. 111 AnildbUna
-- ---- Lot Hamby ----- Tract Mo.
DESCRIPTION OF INSTALLATION i /,-'
ROOFS
• \ l Type of Material ___--_ Manufacturer __ _Thickness_ _R Value"____ � '
4( EXTERIOR WALLS OWEN'S CORNING
\y' Type of MaterialFIBERCLASS BA.TTS FIBERGLASS
Manufacturer_ Thickness_32°R Value" 11
(0r Tref!. Mama)
+�/� CEILINGS OW NS CORNING 64" 19 b:ill
\) Brits: FIBERGLASS BATTS FIBERGLASS 9i" 30
�' Type of Material Manu'acturer Thickness R Value** it
"�. (Or Tnd• Mama)
Sq. Ft. Covered_______ ,•
BLOWN: ,
�' Type of Material --- Manufacturer_ Thickuecs _ No. Sags
�' (Or Trade Nun.) ."
j1 WL/Bay-._—_ Sq. Ft. Covered_ R Value" ,
FLOORS It`��`
y Type of Material Manuracturer __ Thickness__R Value"
��� tarManu)
1\ : SLAB ON GRADE 1)..C..j.;
Type of Material Manufacturer Thickness R Value" _ :k:
(Or Trade Mune) '
Width of Insulation Inches
I FOUNDATION WALLS (H required) \
��: Type of Material__ Manufacturer Thickness__—_R Value"—_
(Or Trade Nem.) •1; ,
REMARKS (if desired) '
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y`_ Gan.r.1_ram...}.._.11Oaidaaa._KAUFMAN. &_.RROATI_ —..— -- _
`� By Title _ Date _
Sub-Contractor (Insulation Applicator Insulation Company License Number_ 274283_
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7 Form 116 —R BUILDING NE , INC., 3055 O.tian; Ave., Los es, Calif. 90031 12131870-971Fom 1e36--.'o BUILoihC INDUSTRY ASSOCiATI•ON OF G1IF ?9ik INC, t51t Bee'I Blvd., Los Anpel.:s, Calf 1 r3;y a• . 4M2� S.- 6.5.577! ,
:. ' s. �oY'� T Kiri t. � � )
O CITY OF COSTA MESA
44I q@@ BUILDING DIVISION
> :
DECLARATIONS t j
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
EIVI 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 l omia, 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 p I
Applicant Signature: Date: 9-(z'-1 - °V
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDITKAN 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 Busin ss and P�rofessions Code,and my license is in full
force and effect.Lic.# _, f j n n 760 S53 Class# y/r cc-
Contractors
L
Contractors Signature: (�y"t,A�Ud-6--.. Date: 7-r -pc7
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:
hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec:7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I,as owner of the properly,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes ❑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 ❑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 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 Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑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
B (If"yet,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-describedproperly��peefor inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
--------��`-J Signature Of lagaLOwner(s) Date
9-/LA -Do
And/Or Authorized Applicant Date
CODE# INSPECTION TYPE BATE )NTITIAI a cQcE# INSPECTION TYPE DAM IML$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy ��
• 6 rnPL tc.2. •
PROJECT ADDRESS: ' • ..UNIT: - • - '- - - . .
awxinsripnf 1052 SPINNAKER RUN 14 _ CITY OF COSTA ,MESA -•,BUIL DING .PERM IT ,
KAUF, ANN E BROAD, :
• ADDREsa: 180 N. RIVERVIEW OR • • PERMIT 1=34'•$ 044965 • PLAN ,CHECK NO: N, GQ.VT: N SUPP: N
%JI TE 300
1. ANAHEIM,''CA 92808, : .CONSTRUCTION TYPE: V-N' . PERMIT__TYPE: `EL MEC PLU STR ' ' •PURPOSE-: NEW
ARCH/ENGINEER: MIKE WODDLEY • ,REc.No.:G1'�� 0 JOB DESCRIPTION ` �: SED. • • - ' _ SQ FT: 2 53.•7
r ::ADDREsa:. • 1$Or, N. •RI VERVI EW DR lr' 3019. s
t. PERMITTEE: EIM CA 92808 - , CLAIM VALUE: 14`4,063.00!: CALC-VALUE:. •144',:063.2.4 GROUP OCC :' ,R-3 IM-I
KAUFMANN £ BROAD' (714)921=0590 :
ADDRESS: 180 N. 'RIVERVIEW DR, - 300 - COMMENTS: PC I1234-89A PD $129.51 " ' - ' ,
-• - ANAHEIM CA 92808 _ . • *************R******ix******************'**s**********************4*************# •
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(co�•mencing with Section •1 0 N I N' G R EAU U I R E M E N T 5
•
7000)of Division 3 of the Business and Professions . • 'ense is in foil force and effect.
SE T B A C K $
Cm LIC.: STATE LIC.:3344. , CLASS: B-1 •
. .
ACCESSORY BUILDING
•
----
-Date: I Signature: ' ---=------=- MAIN BUILDING
WORKER' COM NSATIONDECLARATION: Iherebyaffirmth.- haveacertificateofconsenttoself-insure oracertificateofWorkers' , FRNT: 5 FT IN REAR: '28 FT IN . ;FRNT: , FT IN REAR: FT IN
Compensation Insurance.ora certified copy thereof(Section .4 i,Lab.C). ' -.LEFT: 5 FT IN RGHT: 5 FT IN' LEFT: . 'F T .I N RG HT: - FT , IN - '
POLICY NO.:4189-1090 • EXP.DATE: 03/07/90. I ya[F- add -gyp
COMPANY:TRANS. JN.
S,„
PARKING REQUIRED:. 2 PARKING PROVIDED: 2 PARCEL: .04243310 ZONE: PDRM0
o- y i Certified ipyish ebyfurnished. KJ Cert! -. copyisfile•withthecity'BmidingDiv'ion. . PLANNING NOTES> SINGLE FAMILY RESIDENCE WITH ATTACHED' TWO CAR GARAGE. HALF -
>• ..OPEN. PARKING SPACE PER: UNIT' PROV;I'D D\\F- Q'R"GUE ST PARK I1�; ((��t1
.'':v: , a Applicant . ,}�,(/// /n ***********************************#**7k*******#*•*n**'i4************�*�'a' ••uH
EKEMSDD FROM i RKERS'COMPENSATION DECLARATION:• 7• ion Deed not be completed if Di mut far one huored j$1 0)or less) V t D E V E i L -0 P`+ Mt,,E ,N -Ta r. S s E R OKI i C F ;S , - R- E 0- U I R E M E 1411-•- 'S• '
I certify that in the performance of the work for which this Der ' is issued;I shall not employ any person in any manner so as to become `i • Y •' S{_ • C � . • T:!
subject to the Workers Compensation Laws of California.^' ..• ' •` - i ::x- ' I • .1/ .'j
ZONING APPROVED: BY i' - DATE: _/
Date: ' . Signature . . . . . . .. - - :., :'. __ . . -
NOTICE:If,after making this declaration,you should becomesublect to the Workers'Compensation provisions of the'Labor .BU I LDI NG APPROVED BY f'ES 1 : _ -a' ' -1 �• ' '' �'"' DATE: 67, t-4- '
Code,you must forthwith comply with such provisions or this,permit shall be deemed revoked -'' : , . ' '"'" r .r
•
CONSTRUCTION LENDING AGENCY: Ihereby affirm that,there is:a construction lending agency for the performance of the work for . -APPLICATION ISSUED BY: ' a 21,4101000111"1"1"1"7-
� - '* ` DATE: 1
'
which this permit is issued(Section 3097,Crv.C)'. 441.; -4 i 'Sy; .Y•� ---- • - •
• LENDER: .*****************************5****** • ' ** -*************t************************
ADDRESS: I - - , . LEGALIZATION:N- - . - - - "F E.-E . S ' • M. .M -A - R'Y : STRUCTURAL SEGMENT:Y '
OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason . 3, - i BLDG PMT •' PLUMBING ' 'ELECTR' C ;MECHANIC ' FIRE, SMIP/RES GRADING
(Section 7031.5 Business and Professional Code: .Any city of county which requires a permit to construct,alter,'improve,demolish.or ' PERMIT' , 797,.00 39.50- ' • 69.86 - 1' • 32.75 10:08 ' • - •'
repair any structure.prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed
pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business 2 5$_ , •SD '25$ SMI P/NON-R E S
and Professions Code)or that he/she is exempt therefrom antlthe basis for the alleged exemption.My violation of Section 7031.5 by PLAN '' • • .• . , . •• •
• any applicant for a permit subjects the applicant to a'civil penalty of not more than five hundred dollars($500). , I S SUE FEE 'S00 15.00 - 15.00
'-I, as owner of the properly;or my employees with wages as their sole compensation:evill do-the work, and the ' 'BUILDI NG-DI V-> PERMIT ISSUE ' PLAN-CHECK TOTAL '• I PAID DUE. t
'❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The ContractorsState License Law TOTAL S---->: ..• 949.1.9 ' •• '33.0+0 -- 0.00 ' 982.19 982.19 .00 '
• does not apply to an owner of a property.who builds or improves thereon,and who does such work himself/herself or through '
'his or her own.employees,provided-that such improvements are not intended or offered for sale.If,however the building or
improvement is sold within one year of completion,the owner willhave the burden of praying he/she did not build or improve REVENUE DI VI SION, TOTALS--> .COLLECTED: ` • 982.19 OVER/SHORT: 00 ••
•for the purpose of sale). �. _ .- BLDG P,MT PLUMBING' ELECTRIC MECHANIC FIRE SHIP/TOT GRADINGPLAN-CHECK •
, 4 I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 797.00 42.50 84:86 86 47:.7 5 10.08
❑ and Professions Code: The Contractors'State License Law does not apply to an owner of properly who builds or improves thereon , : -_= ,
and'who contracts for such projects with a contractors)license pursuant to the Contractors'State License Law).,l am aware **************************************k*5************************************5*
• that proof-of their Worker's Compensation insurance should be provided to me. , I 'N D I V 'I D U .A L .;E E E ' B B E A K -0 0 W N.
Elam exempt under Section: B.8 P.C. ° ••
for this reason: '' t - TYPE QTY'. D E S: C R I P T I O N ' UNIT 'COST TOTAL •
• COST
Date: Owner: •
SFR 1996 ' OWE-TYPE V-WOOD FRAME •- ' • -GOOD 67.701 • 135,129.20 •
Ido hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and .
25534 and that l or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements fora SFR 76 RE$-BALCDNYs EXTERIOR STAIRWAY 13. 54 1 ,029.04 •
permit for construction or modification from the AirQuality Management District.Residential construction applications are exempt from SFR • 465 • RES-:GARAGES - TYPE V ' a 17.00 '1 • 71.905.00
these provisions. ', , ELE 1996 - ' NEW RES BLDG FOR i OR 2 UNITS/ SQ FT : .03 • '69.86
MEC 1 INSTALL FORC/AIR FURN <= 100 ,K 8 U/H 9.00 9.00
,Date: Applicant: ' . MEC 1 - REFRIGERATION SYSTEM <= 100 .K BTU/H 9.00 • 9.00 •
I hereby ceeifyth.t I have read this application and st thatt ove information is correct.I agree to complywith at city and county ' MEC 5 ' GAS PIPING SYS 5+. OUTL ETS PER OUTLET . 75 • 3.75
ordinances and s.e laws re.ting to building constructio and hereby horize represe natives of this city en pion the above-mentioned MEG . - 1 FACTORY' FIREPLACE• 6.50 1 6.50
• properly s• ctionp oses. NEC ' 1 ; VENTILATION FAN CONN TO SINGLE DUCT 4.50 ' : i 4.50 •
Date': / I; -1signature �1LtC � PLU • 2 BATHTUB 2. 00 • ' 4.00 .
Driver's L'ense or • cal Security x: PLU 1 DISHWASHER • Di GCw i®RT-?1X4"56. C•r
1 3 : 2.0. ;; .
.
•
GATEL' it!h/ i 'filar' ,7..s
• 1645-46 • While-Building;Green-Code Enforcement:Canary-Applicant;Pink-Revenue:Goldenrod-Assessor ' - .. - -
CONSTRUcTION AND PLANNING • • _ . --. POOL 'A - -
Date Inspector 'Date - Inspector
ct APPROVALS Permit# ' - - _ APPROVALS Permit # • -
• Y 1:Temporary Electrical Service or Pole ' - 52.:Pool & Equipment Location
2.-Soil Pipe-Undrgrnd. cc: m•-.r s N CIA) 53. Steel Reinforcement -
• • 3:•-Electrical Conduit Utility-Undrgrnd: ' 54. Forms- - . •
•
`.4. Electrical Cohdui%Undrgrnd. .1 55. Electrical Bonding •
b..5.rSteerReinfdreemeht - - -• 56. Rough Plumbing & Pressure Test ti
L.•:'6.'Electricel,JFER,Grnd. a'•' G 57.''APPROVAL.TO COVER-GUNITE
est t
- •7,"Footings �. , : . 12,„pi ;q, CIA. 58.- Electrical Conduit-Undrgrnd- i
•
c 8.'-Foundation 59.,Gas Pipe, 0 Undrgrnd.,Test - O•
n.-r�a cls
9.4-Mater Pipe-Undrgrnd. it(rit•(gt -'ED 60. Backwash Lines, P-Trap, 0 Undrgrnd. ,
•
10. StructuralfFloor System ..-" -/- . 61. APPROVAL TO'DECK- -- - '
11. Property Sewer Ling1&1-14se.Connection L � tee U.-Backwash & Receptor-Final
12. Sewer Cap ` _ [ LLL . _ 63. Heater & Vent-Final
13. Roof Drains',-„ . - 64. Plumbing System - Final.'-
. 14. Rough Plumbing - 2(or. ae p VP 65. Electrical-Filial - " -
15. Rough Electric8'I-Conduit '' 66.-Solar, SYstern-Final _
l.
16. Rough ElectricWiring 0140 B,(/-;- 67: Fencing & Access Approval
'17. Rough Wiring Sign - /- /`,dI 68.• APPROVED-FOR PLASTERING ' . •
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL `
19. Rough Heating Air Conditioning ' 7fx(ga C Q ' - - - FIRE DEPT.-REQUIREMENT r
r-: I T--r .: L ` , u < 1?{i rt - r- I,:r.', r . `,;
20. Rough Factory Fireplace 1 • rr e : i qd a;:• •APPROVALS:4Permit # ' ' - 'S"-r•,i r r
21 t Ducts, iii-Striictuie•• I •• 41' - c' `"""'1` _
• v t I ..t...- ,r r:s, h x.70. Underground Hydro Si.
r-'S I r ,.
22.putts, Ventilating,;, 1 , st•L, .: 1-..i},: ,71, Product Piping0Gas 01011
23 4Gas•Pipe.Rough & Test ' 't t� c_ '1 `r '" :72, Underground Flush "- c ""-t
r"i5 1 1-t- LI- 1: L. v cot H ` .. - age • v-•-,.L...,-,a
24{Roof Framing ,� it > * ..73-Undergrnd.Storage,T,ank.OGas 0 Oil
25. Roof Sheathing ' 1 - - `•''hie 74`-Overhead Hydro._ '`
ir
26'T-Bar Cgiling,jStruc'tural) &'Monocoai r, fi "- " 1- it a s' " t a '1' :i l'i
,-t t<^. 7 . - Ca •, 75.. Dry Chemical t L. iF 1, ;.rl`.':n1C•lr .
9 _,• '2 -•� D7, 76. Dry Standpipe i'' -
27. Frame and Flashing; =.c. = v r t % i- _ . - .1 I i - F.r:•-i-i 0~
r a r r: t- a -r,-ec • .,. •+•
28. Lathin t& Siding' s1 - -Pi-r. r, ' Q /! �ei q�, ./' t o -,FIN t. ; c, -�a-+1 "4. ..
,. 9 9 -n1 • Tear ...C4 . , 77:-FIXED SYSTEM FINAL r; t. - ^•_-u, . , <r,..
X29. Insulation V •;.4-2-4 \444/1--;1 78-FIRE PREV, FIOVAL # e yam' �?=;r, -I it
I. ,-.-r r
30. Drywall Nailing c• '`t . 1; 1 -64447:} - ,„ . .. LTH'DEPT'}REQUIREMENE .pn ,.
-31. Plaster Brown Coatir:- 1 rr r: d. c . ! r - ,( ''79: FINAL INSPECTION• - i r r-" Rs'•-
t'32�Electrical Power Meter-Final; . 'h •.vr I ' /..` x •80..-FOOD CERTIFfCATE ISSUED t .'`�' `n r
t.
�p
33/Final Electric. ,` ,t, ; r 1 r ili:sr Noter.• - ",n. v'•r _ -
'34 Final Heating;& Ai;�Conditioning ;'r.,i '�2"/qo 'T.EDj', v ND}iD �l sp ` t c ` -, p..
•35.=Final Gas Pipe-Testa;. _.'. nn.,, ;,3. M qqt? (fO • . - • _ - ft II I-
36. Hood or Canopy if= I or -I ''i-•p.4. cr i t "Mir-;I - - %,c n , a _ �.
-_ - .1 I t_ r . - r s I I [All. n et. .1it/A ` i� a t'e.
•
_37..Final Factory Fireplaces ; r• 1- -t t- - :.r n t- r c' --,
38. Final,Plumbih If "' I r j f �x C •:n ^. t- 1 L • ..
I,,,• - 9 .- rr I t- '_+ Iv LE t•al z ,-tPrt. r c;o' n• �_ r•_L-:cZit r
-39. Water Service-Finalr,. 1 ...,J2.':•r-41G1 i• t' > o i. .. -
J
I 40. Gas Service-Final *4 1r r . ^='f,:t ar 1 I 1 It• 4- �'c.. 1.r t- • 1
r c-• r .t•. _ t I I Ica +. 1-- 4...;.. •-
,41. Solarpomestic-Final' r r'-, I I I ITt f- - c,o .•. y,>c -
, 42. Backflow Preventer est . -•,c 1 I I Irr it c `_}- • r -
I- s,•n, t_ :.. i- -
, -- :r;t n ,- I t,, it r :p..-.
,. C: "d. r. : -. a '. ,r t .-.. ,.. -.�, .�- I
43. Backflow Irrigationz a,.' 1'•4.4. $I. •: i. 1. it t . . . •`. . .-, • •.
44. Landscape Irrigation System ' T•'-',_1 *r t- _ x _ • - 4' r -t �-
-
45••Sound Attenuatioir -1.. ..4y-1. „ 1* .-. -. r Np
46.-Handicap Regulations 48 71 Y�: .�' -`4" ' " C'c• i
. r<v.'F/NAL STRUCTURE& BUILDING<' •i�P1c -64, F+ - r, `' .I " : -y -1
48 :FINALPLANNING. it a. !_ ,.T. S��'i+0;(/�!U!4}W ?- t,. . <• ? r.
49:;Ele'ctricRelia.se to Edison . r r I -, 1 - rt t • L.A..... r
50. Gas:Release•to Southern California Ga%GD =n 11---"i :J t.' Ili i -- - ' . n ,: t-
r. 1 ` ri •• a- f t, r 1: n. .a t. . 0.:C .. I. . .LC ,
51. CERTIFICATE OF OCCUPANCY -' •41• tr t; s- .
"1
No. Date „^
.
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• .
• • -
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- - ., . . .
' , ' • , ' .
O . . ' • -
PROJECT ADDRESS:. UNIT: - • " , .
' . .
: ' , .
AR'S NAME: i 7 - - 7 - '' ' .
• .. f , . .• •
. - • ' ! •
. . — • • .
ADDRESS: • . . ' • , . , ,
.
' . . . • .
,
• . • 2 •
,
•
I .,...--4 o •• ' PERMIT- NO: •G 044965 , • . .. • .,. - -PLAN CHECK NO: -. • - • -
N. PAGE:, •% I
. .
r .
la.. . . •
. . .
• •- • • - . • ! . • 1. '''' . •
f .
f . . • .
AR
C•H/ENGINEER: ,' '• 1 . . . , REG.NO.: ***********.************************************** *******- ****** ****.***. * ***.
t*
ADDRESS
UNIT - • . . ' ... . .• . , .., -
• UNIT COST TOT AL
TYPE Orr • 0 E S C, R I P' T I O ' N .
. . • - . • • " COST
• .•
• . , . • ,
PERMITTEE: . . • •
.P L U 1 i LAUNDRY. TUB OR WASHER -
• - . -• - .
. 2.00 .- • •
, - -• 2.00 ' t f
ADDRESS: - ' • ' . ••• • •
. .
. ' . • PLU il , SHOWER -' .2:00 % • • 4 " • • 2 00 ' L
. • • ,
4 .
.
-,.., • .
Pit) i I SINK, KITCHEN •- ' . 2.00 ' .- • 2.00 :
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 'PLU ' 4 , WASH •BASIN . . . . . :2.00 • • •- . -. 8 :00
, • 7000)of Division 3 of the Business and Professions Code,and my license is in tel force and effect.. • . . . . '
• ' , • -Pit) WATER CLOSET, (TOILET) • • • 4 :2.00 , ' - 6 ..00 ''••
CITY LIC.: ' STATE UC.: CLASS:, ' • PLU • I WATER HEATER 'AND/OR .VENT 2.00 .
, .
' - Z.D0 ' 4
. ,
2.00 • 2.00
,
me- • . Signature: ' 'Pit) 1 WATER SERVICE ' .
.
, . • 2.50 • .
WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' Pill 4 • 5 GAS PI.PING SYS 5+ OUTI-P ER. OUTLET .50 . . . .
Compensation Insurance,or a certified copy thereof(Section 3800,Lab.C). ' , • Pill I GAS SERVICE - ' 24 00 • • • . ' 2:00 - -
POUCY NO.: 4 ' EXP.DATE: • PLU • ' 1 BUILDING SEWER '/ TRAILER • PARK SEWER 5.00 5.00 • :
1.. COMPANY: • . - . END OF FEE S 1. . ,
, , •: 1
. i . .
7 Certified copy is hereby furnished. E) Certified copy is filed with the city Building Division. • •
. . • • • ; ( , .
. ; • . . •
' .
• • ,
. . . . . . . - - " .
. •
' 3 •
J. •Applicant. , • '
• , • • - .
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EXEMPTION FROM WORKERS COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred($103)or less). ; . • . • ' 1 ,MENTS
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. , . • .
,
. . •
• .; , ,
. . .
Date: 'Signature-- • • ' • • • , • • .' ' - • •-•- -• .... _ . • . . . . ,- ' . ,--- •
•
, NOTICE:If,after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor -
•
t
Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. . .i
• .
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for ' ' 1 • . . • .
which this permit is issued(Section 3097,Civ.C). ; . .
. • • ' . •
* . . t
LENDER: • , , . .• . '
•ADDRESS: . . - .-
• -. ' - . '- , • • .. . . - .
• , . .
. , . . . .
, t • . . •- .. . • • , • , .
, •
• ' . . . . .
OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors'State License Law for the following reason ; . . . . • ' " '
. ,
(Section 7031.5 Business and Professional Code: Any city of 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/she is licensed ' . • . , •
' pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business . . •. • - -. i ' .. . .
. , t ,
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.My 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 ' - . ', • 2 •'
. '
I-J structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law . .
does not apply to an owner of a properly who builds or improves thereon,and who-does such work himself/herself or through - • . •
.• . . • '
his or her own employees,provided that such improvements are not intended or offered for safe.If,however the building or . , . •
. . .
' improvement is sold within one.year of completion,the owner will have the burden of proving he/she did not build or improve . • ' . , . • • •
for the'purpose of sale): .... ' ' • . .
' •
. ' -
r , ,
• . -. • . . .
; .
O
I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business , • . ' • • - • '
L_I 'and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon .
. • . ..
' . .
,,
. . and who contracts for such projects with a contractor(s)license pursuant to the Contractors'State License Law).I am aware . . •
. •
that proof of their Worker's Compensation insurance• should be provided to me. ' , • - ' '
' ,
- . ' •
. •
0 I am exempt under Section: , B.8 P.C. • - ' . ' • * ' •
, , •
, • .
, - •
,
for this reason: , . . ' '.
. . .
. .
• 1 .
• .. ' • .
. . • . .
. , . . .
Date: . • Owner • • . ,
•i ' . . . • . •. 1 •
I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and ' 0 , •
. . ,
25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and.the requirements for a . . - . •• ' , .
.
.
permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt from . ,. , . - . . , • ...
these provisions. . . ' . .- I •
. • : •
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I ' .
' • '' ' . ' . • . .
• • .
Date: Applicant: • ' i . . .
, , . •
• • • •
. , . .
, •
I hereby certify that I have read this application and state that the above information is correct.I agree to comply with all city and county • , ,
.
-ordinances and slate laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned . ., - . .
. ' , • .
property for inspection purposes. .. . , I
•
.• •
. ' .
,
Date: , ' • ' Signature: • • ' ,
' , , •
• , • •
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.1
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,
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, • •
,
Driver's License or Social Security•: • . • • '
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- . •
• •
, •
'1641-45 White—Buildino:Green—Code Enforcement:Canary—Aoplicant:Pink—Revenue:Goldenrod—Assessor -- - — . • ,. . ' - ' '
- - - - - - -- . . • ..
CONSTRUCTION AND PLANNING POOL 'A
• -i - Date Inspector APPROVALS Permit # Date. .. Inspector
,•, APPROVALS Permit #
v .
. 1. Temporary Electrical Service or Pole 52. .Pool & Equipment Location � -
_.. r
2. Soil Pipe-Undrgrnd. - . 53., Steel Reinforcement '
3...Electrical Conduit Utility-Undrgrnd. - 54: Forms
4. Electrical Conduit-Undrgrnd. ' 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Presiure Test ' •
6. Electrical UF ER Grnd. - - 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation • - 59. Gas.Pipe, 0 Undrgrnd., Test - i
9. Water Pipe-Undrgrnd. 60., Backwash Lines, P-Trap, 0 Undrgrnd.
. 10. Structural Floor System 61. APP ROVALTb,DECK - .
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final • ,
12. Sewer Cap - - 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System- Final,
' 14. Rough Plumbing65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final •
-
- 16. Rough Electric Wiring 67. Fencing & Access Approval •
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING . . - -
18. Rough Electrical-T Bar Ceiling • 69. POOL/SPA SYSTEMS FINAL .
19.'Rough Heating & Air Conditioning - - FIRE DEPT. REQUIREMENT - -
r o !- co . cr c :-•e- c _
20. Rbugh Factory.F.ireplace- - APPROVALS Permit #
21. Ducts-in Structure 70. Underground Hydro
22.,DuctsiVentilating 71. Product Piping 0 Gas 0 Oil
23. des Pipe-Tough & Test 72. Underground Flush
24a Roof Framing" ` '° "- 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 74. Overhead Hydro
26. T,_Bar;iCeiling (St%c"tuZa l&;Nlorocoat 75. Dry Chemical
27. Frame and Flashiing>;_r� r r, ' 76. Dry Standpipe
28. Lathing &.Sidii,gc 7 ;_r. _,r,,a rt 7 77. FIXED SYSTEM FINAL
29. Insulation?- II- 1,-.+r<.F-".-- 78. FIRE PREV. FINAL
30. Dry wall Na lin?9 r.re:r7r?f=n�mr HEALTH DEPT. REQUIREMENT
r;
31. Plaster:Brown Coat rC�' i i 79. FINAL INSPECTION
!
32. Electrical Power Meter-Final ft.,
32. FOOD CERTIFICATE ISSUED
. t r
33. Final-,Electric Z Kr- u-n_, Notes:
34. Pinal•Heafing 8/Air Conditioning ;�C •
35. F!ibal;Gas Pipe-Test F = �r•
36. Hoodbr Canopy c L.;'
J{
37. Fjnal.Factory Fireplace scn.
38. Final'plumbing "'
h
39. WaterService-Final r, r
40. Gas Service-Final
41. Solar;Domestic-Final
42. Backflow Preventer
4 1
,
43. Backflbw,Irrigaticui. :v.`r.. . .':
44. Landscapeirrigatidn System-'
45. Sound' Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING ,
•
48. FINAL PLANNING -
49. Electric Release to Edison
4;
50. Gas Release to Southean'Californie Gas Co
• 51. CERTIFICATE OF-OCCUPANCY.. r
No. Date a3
F`510 Mac 9 CITY OF COSTA MESA ,
pe BUILDING DIVISION
IY %
DECLARATIONS
l 1 j
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed 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 Califon' $gree hat If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these prOvjsiOns a C7-(47/-.
/
Applicant Signature: C/tel[ Date: / -(/7 ' en)
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED
THOUSAND DOLLARE(S100,000).IN ADOrION 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 and effect.Lic.# 76O "tS 3 Class# B Aire-
Contractor's Signature: Date: •9-/l! '-be.
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 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 drivers license. ❑Yes ❑No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed): •
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application 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 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(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 ❑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.
Or re Of Legal Owner(s) Date
And/Or Authorized Applicant Date
;ODE# INSPECTION TYPE PATE IN�LS CODEI INSPECTWNTYPE PATE BOMSL5
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
CITY OF COSTA MESA
�
-a.
,l f BUILDING DIVISION • PERMIT NUMBER
DEVELOPMENT SERVICES DEPARTMENT.
PERMIT
B00-00602
(714)754-5273 •.Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT ,
Job Address: 1052 SPINNAKER RUN Status: ISSUED
Suite: Applied: 05/01/2000
Vicinity: FRONT YARD Issued: 05/01/2000
Parcel Number: 42451114 Zoning: �y�/)
Applicant: ANDREW DESURRA ISSUED BY: r / //
Address: 1409 E MAYFAIR AV
Phone: (714)402-1275
ORANGE, CA Zip: 92867
Owner: BURLINGHAM, ROBERT
Address 1052 SPINNAKER RUN p '.
Phone: ��
COSTA MESA,CA - Zip: 92627 r
Contractor: . KAD GENERAL CONTRACTOR \go,
Address: 1409 E MAYFAIR AV N\ ` it
Phone: (714)402-1275 JY
ORANGE, CA . •
Zip: 92867 License: 760853
)4
Arch : Eng:
Address: • Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
CONSTRUCT 22 LF OF OF COMBINATION 7-0"HIGH RET WALL AND 1'-6"HIGH BLOCK WALL ON TOP IN FRONT
YARD AREA.
. , FEE SUMMARY ,
Plan Check: , $54.11 Calc Valuation: $2,500.00
Permit: $83.25 . Claim Valuation: $2,500.00
. SMIP Res: $0.00 ,
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $137.36
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
1\ .
DECLARATIONS •
("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 Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed If the permit s valued at one hundred dollars($100)or less.)
tl 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 proveiporp
Applicant Signature: ( .0 Date: 6= 1 -op
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Businesand Professions Code,and my license is in full
force and effect.Lic.N 76e)--€S3 Class it 3
Contractor's Signature: (2.L Date: c-i-cryo
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:
Lem
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 thathe'or shOls 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 suets 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.).
C 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,An 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes 0 N
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Ves ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the 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.
i ature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODES INSPECTION TYPE p INTITULS CODES INSPECTION TYPE - Q!L INTRUIQ
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 V l
2446-46 ,