HomeMy WebLinkAbout201 SUSANNAH PL - Building Permits Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY OF COSTA MESA CONSTRUCTION�PER�MB' PERMIT T Z� TRACT NO. LOT NO. UNIT NO. A P #, Zone
roject Address Su ^ �N L�A C p rr 11 IIyy S Main Building: Accessory Building:
,applicant's Mailing Address 19h22.. Ru MSE' LN , 4113 • TYPE OF CONSTRUCTION U NEW L ADD y�ALTERATION u REPAIR E Front Z
CL
O^t.,` /46
9(90 ❑ CONVERSION ❑ DEMOLISH ❑ OTHE• T O
Owner's Name to Phone 7 1 i �7 ''S1�����C�a B • N
��] p }— DES RIPTIe OF WOR• USE eFB D - < �_ -IA Rear I
•.riddress 2-01 SU.Sfi1J r4,c f �..�CG / W.ia-.�! ! X1_'1 �mtSTa .
�
TYPE OF PERMIT S GRADING U FOUNDATION E' STRUCTURAL I C Right N
Arch/Eng. License No. 3 'Q.8z^' I K G
Address �{I ���� CII TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL $ Left R
Contractor's Nam ,13 a r1Tij t one •:I4 l E :OTHER ,,/ l Ping. Ref.# • Parking Req./Provided E
i '1� ��-• PROJECT DESCRIPTION SQ. FT. 4M461 fief- OCCUPA C R- Q
Address(mailing) 19�2.2- �u I"M7E T v` �" 7� O S Planning Notes: M
1V_l CONSTRUCTION TYPE •X—� VALUATION$ T
City License No. ZONE GRADING CU.YDS. ACRES S.
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks:U!'�O L.. 72...1.7.4.6, ���r',,{ n 1 �oaie"
with section 7000) of Division 3 of the Business and Professions Code,and J 1(�� �o c(• k ELECTRICAL FEES
my license is in full form an6�ect. -IF 7 `�8y �& G - k • 1 2 Ste, • 12L O
License CM; ` `� I icr s: anis L Automatic Washer Transformer
Date _L — /I♦ Signature If .._1. Ji/ ME w- PL MBI NG FEES 0 15.50 KW
OWORKERS'COMPENSATION DEC • RATION Sink Showers Construction Pole Sub. ❑ 50+KW
I hereby affirm that I have a certificate of consent to self-insure ora certificate
of Workers' Compensate Insurance, or a certified copy thereof (Section Cooking Unit Meter ❑up to 100 amps
380 Lab. C �•7' Backflow Preventer Service Sink
Pol' y No. 32-13 CompanyST'/�TE cONP Fut' b Backflow Irrigation
Bathtubs Sewer Cap
Sewer Connection Dishwasher Meter Cloverer 100 amps
CertifiedCery�tcois nerled ywith furnished.thecity ;winging DI isiDryers ❑Gas ❑Electric Sub Panel
iesa py
N. Date `f�L�py"' I Applicant l l.t_� Clarifiers Solar Collectors Fan Motors 00-1 HP ❑1:4—8
EXEMPTION FROM WORKERS'COMP NSATION DECLARATION
(This section need not be completed if the permit is for one hundred ($100)orF,A.U. Inc.Solar 09-15 HP ❑16-15+
less) Dishwasher Solar P' ing
I certify that in the performance of the work for which this permit is issued,I Fixtures shall not employ any person in any manner so as to become subject to the Drinking Fountains ar Tank Micro ve
Workers' Compensation Laws of California.
Date Signature Floor Drains Swimming Pool w/Spa Device Boxes Ole Light
NOTICE: If,after making this declaration,you should become subject to the Outlets Range
Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Switches Sign
I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water Heater Garbage Disposal Standing Sections
Lender's Name Generator ❑0-5 KW ❑5-15 KW Trash Compactor
Lender's Address Kitchen Sink Water Service
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash
following reason (Section 7031.5 Business and Professional Code: Any city or
county which requires a permit to construct,alter,improve,demolish or repair P—Trap Laundry Trays
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
Roof Drains
the Contractor's License Law(Chapter 9(commencing with Section 7000)of
Division 3 of the Business and Professions Code) or that he/she is exempt Reinspection Fee $15 Issue Fee $ 3
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
enalty of not more than five hundred dollars($500). $ 3 DEVELOPMENT SERVICES REQUIREMENTS:
I, as owner of the property or my employees with wages as their sole Reinspection Fee I $15 Issue Fee Zoning Approved By Date
compensation, will do the work,and the structure is not intended or offered -
for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES Building Approved By / Atilt Date
License Law 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 Application Issued By sassifr,'._-. Date : -
employees, provided that such Improvements are not Intended or offered for Boiler Hood or Type I ❑
sale. If, however, the building or improvement is sold within one year of com- Canopy Type II 0 SUM •RY OF EE/,
pletion, the owner will have the burden of proving he/she did not build or im- Duct-Under Ground
prove for the purpose of sale). BUILDING PERMIT $ 72 • 00 SMIP $ • 3 e
❑ I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System PLAN CHECK $ PERMIT
tractors to construct the project (Section 7044,Business and Professions Code: i
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating ❑0.100000 BTU 0100,000 BTU PLUMBING $ _ ISSUANCE $ -builds or improves thereon.and who contracts for such oroiects with a con- - ENERGY P.C. $
tractors license pursuant to me Contractor's License Law). I am aware that Exhaust System 0 Multiple 0 S em Repair/Alteration I PLAN CHECK 25% $
proof of'
their Worker's Compensation insurance should be provided to me. GRADING $
0 1 am exempt under Section B.& P.C.for this reason Firepl/Fact.Bit. ICBG# Fire Dampers ELECTRICAL $
PLAN CHECK 50% $ MICROFILM $
Date Owner Heating System& Ducting Registers MECHANICAL $ ( 2 SDI hereby certify that I have read this application and state that the above CIO-100,000 BTU ❑100,000BTL ' TOTAL FEE $
information is correct. I agree to comply with all city and county ordinancesPLAN CHECK 25% $
and state laws relating to building construction,and hereby authorize repre- \
sentatives f this city to pnt u he bove-mentioned property for inspection poses. 'VU_� �Z— 119
r
Signature Date
Drivers' License or SS# — - Reinspection Fee $15 Issue Fee $ 3 S r^Os 1 _000r31710-00031711 TOT ' _
0865.46,rev. 5/88 White - Building; Canary -Applicant; Pink -Accounting; Goldenrod - Assessor D TE l`•/rye `1 TIME; 13154
`i; t \�\
elitISTR!UCTION AND PLANNING POOL& SPA
•APPROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector
1. Temporary Electrical Service or Pple 52. Pool & Equipment Location
• 2. Soil Pipe-Undrgrnd. ',.� - 53. Steel Reinforcement
S. Electrical Conduit Utility-Undrgrnd. u • 54. Forms
4: Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement `'.' . •- 56. Rough Plumbing & Pressure Test
- I .
6: Electr.icalUFERGrnd -�l; 57. APPROVAL TO COVER-GUNITE ,
7'.'. Footings tit 58. Electrical Conduit-Undrgrnd.
8:- Foundation 59. Gas Pipe, 0 Undrgrnd., Test _ '
9. Water:Pipe-Undrgrnd. • •
60. Backwash Lines, P-Trap, O Undrgrnd.
10.; Structural Floor SS•stem " , 61. APPROVAL TO DECK
11: Property Sewer Line & House Cornnection - 62. Backwash & Receptor-Final
12. Sewer.Cali. 63. Heater & Vent-Final
13. Roof Dralins 64. Plumbing System - Final
14. Ro;ugh Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
16' Rough Electric Wiring 67. Fencing & Access Approval
17;. Rough Wiring Sign 1 68. APPROVED FOR PLASTERING
18. RoughElectrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough'Heating& Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace i L • APPROVALS Permit#
21. Ducts,in'Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-Rough & Test _-' / 72. Underground Flush
24. Roof Framing •
73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing • i 74. Overhead Hydro
26. T-Bar eiling (Structural) '&`.Monocoat 75. Dry Chemical
27.iFrarne,and Flashing i 76. Dry Standpipe
28. Lathing &-Siding 77. FIXED SYSTEM FINAL
r.
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat - 79. FINAL INSPECTION
32. Electrical Power Meter-Fina! 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final - f
41. Solar Domestic-Final `
le If
42. Backflow Preventer -•�
l '
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation fO'l( � sQ t -
46. Handicap RegulationsOP r, °ebl
47. FINAL STRUCTURE & BUI LDING Q-7 6/4„
Lit
Special Requirements Completed P v
49. Electric Release to Edison r'.
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY •', cJ
No. Date ;..
PflOADDRESS: 201 SUSANNAH PL UNIT: CITY OF COSTA MESA — BUILDING PERMIT • PERM NO: E 046829
OWNER'S
R'S NAME: ROBERT & MEL OLONA •
ADDRESS: 201 •NeSANNAH PL PERMIT .NO: F. • O'4682ii PLAN CHECK NO: N GOVT: N SUPP: N
• C%'STA MESA ,
CA 92627 `CONSTRUCTION TYPE: 5—N •
PERM•
IT TYPE : ELE PURPOSE: OTH
ARCH/ENGINEER:
( 714 ) 645-9190 ` REG.NO.:
JOB DESCRIPTION : REPLACE 100 AMP ELECTRICAL SERVICE - .S FT:
ADDRESS: , UNIT: - Q
PERMITTEE: CLAIM VALUE: CALC—VALUE: GROUP OCC: R-3 /
ADDRESS" HUNTER ELECTRIC ( 800 ) 729-4868 •
-
9292 MAGNOLIA COMMENTS:
•
• RIVERSIDE CA 92503 • ***************+ #34-*****X.*u-,6***+r+tsc* -x*st*** * ****,f* ***s6N******.+E * ******** ***
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section z ONING R E' QU I R E M E N T' S
' 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. S F. T IIA C K S
uitue.: 043465 STATE LIC.:313229 uiss: C-1 -- - ----- --
(�j .
Date:Y— �S= p0 Signature: �—� ��/� � -- , - -- MAIN BUILDING - ACCF.S SORY BUILDING- -•---------
WORKERS'COMPENSATION DECLARATION: I hereby affirm hat l have acenificate of consent to self-Insure or a certificate of Workers' FRNT: FT IN' REAR: FT IN FRNT : FT IN REAR: FT ' IN
Compensation Insurance,or a certified copy thereof(section 3800,Lab.q. LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT TN
POUCY NO.: N 10 0 6 4 8 9 A EXP.DATE: 02 /1'7/91
COMPANY: CALIF INDEMNITY PARKING REQ: PROV: PARCEL : 43918120 ZNE: REF NO:
❑ Certified copy is hereby furnished. ig. Certified copy is f with the city Building Division �� PLANNING N(jTES> - - - -
p 1�l C • >
Date: Y—� C O Applicant 4.y. ,,/ . ********************************4*-4********************************************
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need hat be completed if the permit is for one hundred($100)or less). DEVEL 0• P MEN T :-S"4E,-R V I CES REQUIREMENTS
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. ZONING APPROVED BY • � i DATE:
.
• _- .
Date: Signature: ' • - •- ' • ' -- ---- .
NOTICE:If,atter making this declaration,you should become subject to the Workers'Compensation provisions of the Labor, BUILDING . APPROVED BY : __, ' DATE : '
Code,you must forthwith comply with such provisions or this permit'shall be deemed revoked. / -" ' - —"------- ------ -
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for ' APPLICATION ISSUED B Y:
which this permit is issued(Section 3097,Civ.C). **********************n* . . • ` ! - DATE: 40e Q
LENDER: ********************************X'**********- fe**3E***********************7E*******
ADDRESS: LEGALIZATION:N FE E S, U M M A R, Y STRUCTURAL SF.GMFNT:N
•
OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING , ELECTRIC MECHANIC FIRE SMIP/RES GRADING
(Section 7031.5 Business and Professional Code: My city of county which requires a permit to construct,alter,improve,demolish,or
PERMIT - 18 . 5 0
repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed -
andsuant to theProfessions Code)or that he/sheons of the ristors'State License Law exempt therefrom and the basis Tter 9 oroth the exemption.with Any violation)sion 3 of of'Section 7Business
31 5e by PLAN •
- s 0% sM I P/rlaN--R Es,
any applicant far a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). ISSUE FEE • 15 . 00
I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK- TOTAL • PAID DUE
❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law TOTALS--——> . 18 . 50 ' 15 . 00 0 . 00 33 - 50 33 . 50 . 00
does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through -
his or her own employees.provided that such improvements are not intended or offered for sale. If,however the building or •
improvement is sold within one year of completion,the owner will have the burden of proving he/she did not build or improve REVENUE DIVISION TOTALS--> COLLECTED : 33 . 50 OVER/SHORT: 00
for the purpose of sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/TOT GRADING PLAN—CHECK
I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044.Business 13 . 50
❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon
and who contracts for such projects with a contractor(s)license pursuant to theContractors'State License Law).,I am aware ***********.aE************************* *****-************************.*.*Xit.K.**X-)****
that proof of their Worker's Compensation insurance should be provided to me.
❑ am exempt under Section: B.&P.C. _ I 11 D I V I D U A L F E E B R E A K D O 14 N •
for this reason: TYPE QTY D F S C R I P T I O N UNIT COST TOTAL COST
Date: Owner:
I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505.25533,and ELE 1 S ER V T.C F BELOW 600 V & B E T,OI4 201 AMP 18 . 50 1 ($ , 50
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 aEND OF FEES
permit for construction or modification from the Air Duality Management District.Residential construction applications are exempt from •
these provisions.
Date: • Applicant: -
•
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 state laws relating to building construction antl[orauthorize representaUv ciJt -mtionedupon •
propertyforinspection purposes.Date: •'.' X90 Signature: e
•
Driver's License or Social Security M: is01 00057936-00057936 T 0 T 33.50
-t641-46 White-Building:Green-Code Enforcement;Canary-Applicant;Pink-Revenue:Goldenrod-Assessor • DATE: 04I05I90 TIMES 1359 -
CONSTRUCTION AND PLANNING - • POOL & SPA
•
APPROVALS Permit# Date Inspector APPROVALS Permit Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. • 54. Forms-
4.'
ectrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVE R-GUNITE '
7. Footings 58. Electrical Conduit-Undrgrnd. i
•
.8. Foundation i ) 59. Gas Pipe, 0 Undrgrnd., Test ---+
' 9. Water Pipe-Undrgrnd. 11 / `/. 60. Backwash Lines, P-Trap, 0 Undrgrnd. --I;
10. Structural Floor System 61. APPROVAL TO DECK '
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
•
12. Sewer+t'ap � - 63. Heater & Vent-Final -'7
13. Roof Drains '? 64. Plumbing System - Final
`
14. RougPlumbing
h .y- /• 65. Electrical-Final !
I
15. Rough Electrical-Conduit /, ' 66. Solar System-Final /
16. Rough Electric Wiring 4/ 67.r Fencing & AccessApproval `/
17. Rough Wiring Sign f 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling / 69: POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20.- Rough Factory Fireplace APPROVALS Permit#
21. Ducts, in Structure , 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-Rough & Test - 72. Underground Flush
24. Roof Framing ' 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing - 74. Overhead Hydro
26,:T-Bar Ceiling (Structural) & Monocoat • 75. Dry Chemical
27.,Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation ' 78: FIRE PREV. FINAL
30. Drywall Nailing - HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat %. 79. FINAL INSPECTION
.32. Electrical•Power Meter-Final ` 80._FOOD CERTIFICATE ISSUED
33. Final Electric 7 Yea �; Notes:
34. Final Heating & Air Conditioning f'
35. Final Gas Pipe-Test
36. Hood or Canopy - ,
37. Final Factory Fireplace
38. Final Plumbing ' ,�
i
39. Water Service-Final -•
40. Gas Service-Final ' •
'41. Solar Domestic-Final • .
42. Backflow Preventer
43. Backflow Irrigation •
44. Landscape Irrigation System -
45. Sound Attenuation - •
46. Handicap Regulations •
47. FINAL STRUCTURE & BUILDING ° -
48. FINAL PLANNING
,
49. Electric Release to Edison
'S0:Gas Release to Southern California Gas Co f1
r .
51. CERTIFICATE OF OCCUPANCY
No. Date
CITY OF COSTA MESA
44- BUILDING DIVISION
F •"•-'-r .� DEVELOPMENT SERVICES DEPARTMENT
�• PERMIT PERMIT NUMBER
l‘b4oxino`se
B98-01732
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 201 SUSANNAH PL Status: ISSUED Lb
Suite: Applied: 09/25/1998
Vicinity: Issued: 09/25/1998
Parcel Nunmber: 43918120 Zoning:
Applicant: SULENTIC, DAN
Address:
Phone:
Zip:
•
•
Owner: ERICKSON,'SONYA F
Address 358 KINGSLEY AVE _
Phone:
PALO ALTO,CA Zip: 94301
Contractor: SUNCASTLE CONSTRUCTION
Address: 10425 DOZIER DR
Phone: 636-2763
GARDEN GROVE,CA Zip: 92843
License: 634368
Arch/,Eng :
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
CORRECTING MINOR UNEVENESS OF SUBFLOOR-PATCH,REPAIR,AND STUCCO AT PERIMETER OF
BUILDING. REBOLT PERIMETER W/RETRO HARDWARE. INSTALL WEEP SCREED OM EXTERIOR.NO
PLANS REQUIRED PER.RICK BROWN, C.B.O.. -
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $8,100.00
Permit: $149.75 Claim Valuation: $8,100.00
SMIP Res: $0.81 -
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $150.56
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:
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
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:
Carder: Policy Number
(This section need not be completed if the.+••••• is valued- . : . dred dollars($100)or less.)
❑ I certify that in the perils'. .nce of,,%t orrksu
k . which this •ermlt smart, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of :lifomia, - agre:'t : If I shout. •ecom' subject to the workers'compensation provisions of Section 3 0 of the La Code,I shall forthwith
comply with these• 'visions. /
Applicant Signature: / 4/" (�'a Date: ( 7sr5T / p ej
WARNING:FAILURE TO SECU•,6.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 DECLA T
i
I hereby affirm that I am license oder ision 61 .pter 9( • menc.r.4 with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.tic # / , n / - Class# /
Contractors Signature:✓ /C� — Date:I y(/Z 5
/6
CONSTRUCTION LENDING AGENCY:
O 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 drivers 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,faisework,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 Corm for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health end 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 ❑N0
(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 appermit 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 ❑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
B (If'yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized bybythis/ispermit untilnt�final inspection.
�� �• / /Sjgggt Ot L;,- Owne )� !! 2 7 Date
An•Or Au, . Zed Applicant t Date
CQOE I./ INSPECTON TYPE GATE D1MAL5 CODE I INSPFCTON TYPE DAM MMUS
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/Occupancy2-r '(ATT) ./9%2 / E 4 �rt; I
,,.44&CB+•c,en,-- .e,.••v...,=:_,,,e,c=--�o_-esrsaz,.>r..s..v.m_t-.x_-:c ,m- .. - - a.-a-.a_: 3 -ac...=__..7,c_, -: -•.s.._n.
17367 �FE RECEIVED
JUN7� 67
COSTA MESA BUILDING-SAFETY DEPARTMENT ',t
P. O. BOX 317 COSTA MESA. CALIFORNIA CI//L f fi11NCE DEPT.
Applicant to Fill In Completely CITY OF COSTA MESA
For A
PP � P Y APPLICATION FOR PERMIT
TYPE OR P- T
-ct' i / a'"' / BUILDING
BUILDING / ,r
ADDRESS (74v M •
~.
COSTA MESA. CALI ORNIA For Office Use Only
�I �� // .f/ RECEIPT NO. P RMIT NO.
OWNER /� i�/ l/. /`'N,� � /73 c 7
MAIL 333 �` ' REOEIV'D BY I DA R.E. D DATE ISSUED
ADDRESS �_ .
T
CITY -2117 NO, •'C% 2 ADDRESSG 4 f•-_-L o
COSTA MESA. CALIFORNIA
FIRE .2 ///
• / ZONE PE (/ GROU' //�j(��{/
\/IMIEW�� /
APPROVED •4' DATE i -T 4
ADDRESS . e2,771.-{.r ZONING
< ZONE NO.OF 7 USE OF NEW_C; 7p.• 1'
.A.
CITY K—a I PLANS (^ BUILDINGQ4 J-e— .c
LEGAL
LIC.TNO. //�[.�1�/C�f7OQf f'A NO. DESCRIPTION L--sH 7/X 6. G /
SIZE
OF LOT / ! /1 C/DC I No. OF BLD68. A
NOW ON LOT Ll A.P.NO.
USE OF YARDS EVES
EXISTING BLDG APPROVED ALLOWED
SETBACK LINE FROM i 4CENTER LINE ST.I
CENTER OF STREET SO REAR YARD ' FRONT 0 FT. O/a'}•_Q IN.
SIDE YARD I LEFT I RIGHT R.SIDE 9 FT. IN.
DESCRIPTION OF WORK L.SIDE / FT. f—/y__ N.
NEW I /I II ALTERATION I II ADDITION REAR FT. 474../' IN.
REPAIR I II MOVING I DEMOLISH I BYPROVED. A-1�` DATE "/>/�L
S ZE DING/337 ROOMS IC7 STO ES / 4/L
+K'/ - /f 2/4 G
EXTERIOR WALL cl 1 ROOF �/ I r __ (fi..
COVERING COVERING � /
USE OF BUILDING AND WORK TO BE PERFORMED
Gi.,(4-/-9,6,,En dc 1 /r7hy.�'a c L/f /s�/iT =/33:
I HEREBY ACKNOWLEDGE THAT I HA READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM-
PLY WITH ALL CITY ORDINANCES ND 88Tj/�TE �LAWWSS/�REEJGIU./LATING PURPOSE OP ESTABLISHING A PERMIT FEE ONLY.
BUILDING CONSTRU�^: y�Nv"/" 'V VALUATION /J
I/ A.y3 PERMIT FEE Ar---
.
SIGNATURE OF / $ N
PERMITTEE [f/ �/ �7[/ _
$ // 1/4 / PLAN CHECK 5 �t / '� .m
S .
AUTHORIZED AGENT �l o
TOTAL FEE 02. r u,