HomeMy WebLinkAbout330 15TH ST - Building PermitsJob Address: 330 E 15TH ST
Suite:
Vicinity:
Primary Occ: R-3 Dwellings/ Cong Res <10 Type of Construction: V -N
Parcel Number: 42531101 Zoning:
Applicant: NIEMANN, DAVID KAIMI
Address: 1273 STARLIT DR
Phone: 415-871-9945
LAGUNA BEACH, CA Zip: 92651
Owner: SAMUELIAN, STEPHEN E
Address 20371 IRVINE AV
SUITE 210 Phone:
SANTA ANA HEIGHTS, CA Zip: 92707
Contractor: DAVID KAIMI NIEMANN
Address: 1273 STARLIT DR
Phone: 415-871-9945
Status: ISSUED
Applied: 01/05/2005
Issued: 05/30/2007
ISSUED BY: sf�
SCOPE OF PERMIT
CONSTRUCT NEW 1884 SF 2 -STORY SFD (831 SF FIRST FLOOR AREA AND 1053 SF SECOND FLOOR) WITH A 420 SF 2 -CAR ATTACHED
GARAGE. THERE WILL BE A SUPERIOR FIREPLACE (MODEL RD -36; WH REPORT J9902 -5865C-23) IN THE GREAT ROOM AND MASTER
BEDROOM, ALSO CONSTRUCT 132
SF PATIO COVER.
3 BEDROOMS, 2-1/2 BATHROOMS
REF: G04-00023 AND PA -04-22
FEE SUMMARY
Plan Check: $962.62 Calc Valuation: $166,415.44
Permit: $1,480.95 Claim Valuation: $0.00
SMIP Res: $18.64
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $2,462.21
SETBACKS
MAIN STRUCTURE Front 0-0
ACCESSORY
PARKING
Front 0-0
Existing: 0
PLANNING & ZONING
Rear 0-0 Left 0-0 Right 0-0
Rear 0-0 Left 0-0 Right , 0-0
Required: 0 Proposed: 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandon d
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 cgdes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of{ti(s permit.
FOR INSPECTIONS CALL: (714) 754-5626 J
2446-46 (SM)
LAGUNA BEACH, CA
Zip: 92651
License: 828096
Arch :
BRADFORD C SMITH, ARCHITECT
Eng:
JAVED S CHAK
Address:
365 OLD NEWPORT BL
Address:
SAMA
STE B Phone: 949 631-3682
LAGUNA HILLS, CA Phone: 949-421-1090
NEWPORT BEACH, CA _
23141 VERDUGO DR STE 102
Zip'.
92662 License: C14146
92653 License: CE24605
SCOPE OF PERMIT
CONSTRUCT NEW 1884 SF 2 -STORY SFD (831 SF FIRST FLOOR AREA AND 1053 SF SECOND FLOOR) WITH A 420 SF 2 -CAR ATTACHED
GARAGE. THERE WILL BE A SUPERIOR FIREPLACE (MODEL RD -36; WH REPORT J9902 -5865C-23) IN THE GREAT ROOM AND MASTER
BEDROOM, ALSO CONSTRUCT 132
SF PATIO COVER.
3 BEDROOMS, 2-1/2 BATHROOMS
REF: G04-00023 AND PA -04-22
FEE SUMMARY
Plan Check: $962.62 Calc Valuation: $166,415.44
Permit: $1,480.95 Claim Valuation: $0.00
SMIP Res: $18.64
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $2,462.21
SETBACKS
MAIN STRUCTURE Front 0-0
ACCESSORY
PARKING
Front 0-0
Existing: 0
PLANNING & ZONING
Rear 0-0 Left 0-0 Right 0-0
Rear 0-0 Left 0-0 Right , 0-0
Required: 0 Proposed: 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandon d
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 cgdes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of{ti(s permit.
FOR INSPECTIONS CALL: (714) 754-5626 J
2446-46 (SM)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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.
r0 have hh 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 carder and policy number are:
.Gorlsr _ T- Pp[/ icy Number ='
'-(itls section need not be completed it the permi is valued at one hundred dollars ($100) or less.) L�--
jn, I certify that iJeedio, Lance 1 >r which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers'
compensatiogr a hat if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with (I IApplicenfSlgneture
C `
WARNING: .IN---
FAILURETO ( SECURE WARNERS' P OST O COVERAGE IS UNLAWFUL AND SHALL SUBJECTAN N EMPLOYER TO CRIMINAL PENALTIES ANDGVI, FINES TO TOONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirn that I am licensed under pr ' i syj,Crhspier 9 (commencing with Section 7000) of Division 3 of the Business and Rrofessions Code, and my license is in full
rforce'and eHecCClc: #---- �Jf�jjbb Glass.#. _ -ij C, is
ContrectorsSi07
gnature:--- ✓ate- - 'SO
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). '
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors)
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:
❑ 1 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 —ore than thirty-six (36) teat 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? ❑ 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).
.......................................................................................................................................................................................................................................................................................................................................
.............................................prase ..
2 Does or will the applicant or present or future building occupant need to file a registration forth 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 en RMPP is pre.......ently required, has Section 25534 of the California Health and Safety Cade been fully complied with? ❑Yes ❑ No
5 Dams ar will
he applicant Air
or present or future building occupant require for the work which Is the subject of this a plication 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 California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility io 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 preser bed by Calitomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
............................................................................................................................................................................................................................................................................................................................................................................................
8 (It'yes", attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all stale 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.
ZL Si to Ot Legal Owner(s) Date
S . 2rJ •
-77Ani Mthorl Applicant
CODE t. INSPECTION TYPE INTUl6S CODE r INSPECTION TYPE (LATE INITIALS
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 -- 5
NEWPORT -MESA UNIFIED SCHOOL DISTRICT
CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES
PURSUANT TO AB 1600 AND AB 181
To: City of Costa Mesa
City of Newport Beach
( ) County of Orange
Applicant:
Address
Telephone Number: ( j
Tract/Parcel and Lot Number(s):
Location of Project:
Number of Square Feet of:
Residential Space
6
Commercial and
„ Industrial Space
CommercialAndustrial Project is: (Check One)
c-919!�$1.84
= 'Z -7,Q �_)
x $ .30
N2 6631
District Receipt No.
Plan Check No. ,ems -ice r
TotalI "-00
y
Total
_ Warehouse
Motel
Preschool
R 8 D
Bank
Auto Repair
Movie Theater
Neighborhood Shops
Hospital
Mini -storage
RacquetlHealth
Large Office
Heavy Industrial
Hotel
Office Bldg.
Regional Shops
Medical Office
Restaurant
Light Industrial
Office Park
Fast Food
This project is exempt because
This certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Govemment Code sections
53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction.
Checks are to be made payable to Newport -Mesa Unified School District.
Authorized Representative
The above representation as to square footage is true. Applicant agrees that if it is later determined that such representations are not
true, then this certificate shall automaticaly terminate and th appropnat City/County shall be notified.
Date
AppiaPo
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address: 330 E 15TH ST
Suite No
Vicinity:
Parcel Nunmber: 42531101
Applicant: STIEFEL, LINDA L
Address: 3359 VIA TIVOLI
Phone: 949-350-2867
COSTA MESA, CA Zip: 92626
Owner: STIEFEL, LINDA L
Address 3359 VIA TIVOLI
Contractor:
Address:
Phone: 949-350-2867
COSTA MESA, CA Zip: 92626
Phone:
Zip:
License:
Status: ISSUED
Applied: 08/17/2004
Issued: 08/18/2004
ISSUED BY: ocr_--�
SCOPE OF PERMIT
DEMOLISH 1,378 S.F. S.F.D. CAP ELECTRICAL AND SEWER CONNECTION. REF.: B04-01455
APPLICANT WILL CONTACT A.Q.M.D. PRIOR TO DEMOLITION.
Quantity
ISSUE FEE
$23.50
Temp service test
$0.00
Temp Dist System / Lighting
Res. a/c package
$0.00
Busway /100 it
J New Res (1-2 units)
$0.00
0
�{ New Res (3+units)
$0.00
0
Pool / Spa
$0.00
0
Lighting Fixts
$0.00
0
Recept Outlets
$0.00
0
Switches
$0.00
0
Non Res Appl
$0.00
0.
Res Appl
$0.00
0'
Service to 200a
$0.00
0
Service to 1000a
$0.00 '
0
Service over 1000a
$0.00
0
Motors to 1hp
$0.00
0
Motors to 10hp
$0.00
0
Motors to 50hp
$0.00
0
Motors to 100hp
$0.00
0
Motors over 100hp
$0.00
0
Communication drops
$0.00
0
Sub panel to 200a
$0.00
0
FEE SUMMARY
Quantity
Temp Dist System / Lighting
$0.00
0
Busway /100 it
$0.00
0
Standing Section
$0.00
0
" Misc Electrical Equipment
$0.00
0
. - Transformers up to 1 kva/kw
$0.00
0
................up to 10 kva/kw
$0.00
0
.................up to 50 kva/kw
$0.00
0
.................up to 100 kva/kw
$0.00
0
....:.............over 100 kva/kw
$0.00
0
Low Voltage Equipment
$0.00
0
Low Volt Wiring System / Ckl
$0.00
0
Misc. Conduit
$0.00
0
Misc. Conductor
$0.00
0 ;
Circus ( gen or ride)
$0.00
' 0'
Circus (mech ride or lights)
$0.00 "i
0
Christmas Tree Stand
- $0.00 '
0
Fireworks Stand
$0.00
0
Other Electrical Fee ' .
$9.80
Investigation Fee
$0.00
Plan Check Fee
$0.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with a able codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the rahon of tchis permit.
FOR INSPECTIONS CALL: (714) 754-5626
244646 (6/00)
WORKERS' COMPENSATION DECLARATION:
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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.
❑ 1 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 c plated it the permit Is valued at one hundred dollars ($100) or less.)
y' I certiy that in the pe rm a of the worR'for WhieKIr ermit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensallOn•lewsof, alit nie� n agree th4H haul come sub] the workers' compensation provisions of Section 3700 of the Labor Cade, I shell forthwith
comply w`�,,itt�h these provisI s g , - I /
gppNcam_!STgnre: -'- - / y,rDate:, X -
MING. FAILURETO RE WO ERS' COMPENSATION COVERAGE Id6NUAWFUL D SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLARE ($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 affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
force and effect. Lic. # Class #
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 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).
Landers Name: Lenders Address:
Signature: Date:
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ I, as owner of the property; or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is
so 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.).
6 I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
ts. Code: a cont Is License qes nol.gpply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors)
license r t td the ontra ors nse Le s.).
11KI am axe n of se .
-.
-OvYne edfied by mars license. Ye ❑ No . DriversLlcense N Expires:__
Verification of Ownership by (type of dmrdol, i.e. - property tax bill or dead):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 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 B, 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 hes a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to 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 ❑ 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? ❑ Yes ❑ No
.......................................................................................................................................................................................................................................................................................................................-...................... .................. - .......................
5 Does Or will the applicant or present or future building Occupant require for the work which is the subject of this a plication a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes NO
(Section 65650.2 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
(It yes', the facility must meet the .................... requirement of Sections 25534 and 42303 of the California Health and Safety Code).
......
................................................................_........ .........-....................................... _........._...........................................................................__............................................................................-......................................................_..
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
............._.................._.............ific........of compliance
_._.._...____.........................._.............ntrol........................__...............__.._.__._._...._..__..._.......................____........_.....__.._...................._...........................
8 (If yes', attach certificate of compliance from the eppropdate elr 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:
CERTIF4 TE OF COMPLIANCE ANDA RATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
caftan. I gree p1mtpply wlth all" le laws city c7dinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
�bova-d3 property f r insDection� rpos s. I e r� not cupy or allow occupancy of any building authorized by thy'� permit until final inspection.
I S ure0 gal,r(s) :Date y
And/Or Authorized Applicant Date
CODE r. INSPECTION TYPE INTRIA.4$ CODES INSPECTION TYPE INTITIALS
1616 Fixed System Final Fire Preventlon 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Root 210 Final Electrical
1
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
7
,%g
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
PLUMBING PERMIT
Job Address: 330 E 15TH ST
Suite No
Vicinity:
Parcel Nunmber: 42531101
Applicant: STIEFEL, LINDA L .
Address: 3359 VIA TIVOLI
Phone: 949-350-2867
COSTA MESA, CA Zip: 92626
Owner: STIEFEL, LINDA L
Address 3359 VIA TIVOLI
Contractor:
Address:
Arch / Eng :
Address:
Phone: 949-350-2867
COSTA MESA, CA Zip: 92626
Phone:
Zip:
License:
Phone:
Zip:
License:
Status: ISSUED
Applied: 08/17/2004
Issued: 08/18/2004
ISSUED BY:
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 susor 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 ; y
2"648 (SMO)
SCOPE OF PERMIT
DEMOLISH 1,378 S.F. S.F.D. CAP ELECTRICAL AND SEWER CONNECTI�B04-01455
APPLICANT WILL CONTACT A.Q.M.D. PRIOR TO DEMOLITION.
FEE SUMMARY
AMT
QTY
AMT
QTY
AMT
QTY
ISSUE FEE
$23.50
Laundry Tub / Washer $0.00
0
Sump Pump
$0.00
0
Backflow irrigation
$0.00
0
Landscape Irrigation $0.00
0
Swimming Pool
$0.00
0
Backflow Preventer
$0.00
0
P -Trap $0.00
0
Trap Primer
$0.00
0
Bathtub
$0.00
0
Pressure Regulator $0.00
0
Urinal
$0.00
0
Clarifier System
$0.00
0
Process Piping (per 10 ft) $0.00
0
Vacuum Brkr Bkflow(1-4)
$0.00
0
Connect (Ice,Soda,etc)
$0.00
0
Receptors $0.00
0
Vacuum Brkr Bkflow(5+)
$0.00
0
Dental Units
$0.00
0
Septic Tank $0.00
0
Wash Basin
$0.00
0
Dishwasher
$0.00
0
Sewer Cap for Demo $9.80
1
Wash Basin Set
$0.00
0
Drain, Floor
$0.00
0
Sewer Connect $0.00
0
Waste and Vent System
$0.00
0
Drain, Rainwater
$0.00
0
Sewer Private Line $0.00
0
Water Closet (Toilet)
$0.00
0
Drain, Roof
$0.00
0
Shower $0.00
0
Water Heater / vent
$0.00
0
Drinking Fountain
$0.00
0
Sink, bar $0.00
0
Water Piping (Inst or Rep.)
$0.00
0
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 susor 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 ; y
2"648 (SMO)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certllicate 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 Cade, 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 (SIR) or less.)
certify that In the pert a 6e of the viork'fd whlch in permit iso sued, I shall not employ any person in any manner so as to become subject to the workers'
��+compensallon laws,oi_C t0 omla; and gree the llh,,��� shout come subject))) the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with t ase Drovi `con; _ / , D (/ /
may' St neturr wy�� rcl/ �� �-Date:,_ T
WARIN Nl 6"FA� RE TO SECURL'/WORKERS' COMPEN COVERAGE UNLAWFUL AND SHALL SUBJECT AN EM TLI CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED
THOUSAND DOLLARE(5100,000), IN ADDMON TO THE COST OFCOMPEN TION, DAMAGES AS PROVIDED FOR IN SECTION 3T060F 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 affect. Uc. R Class x
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there Is 8 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
Coda: 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 Prolessions'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. It, 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.).
1; as owner of the property, em EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Cotle:I "V cOy(ectOrs License,la not apply loan owner of properly who builds or Improves thereon, and who Contracts for such project with a contractors)
licens4ursYuan( to in.= Uce Laws.).`
I am ex t nd r se . usiness and Professions Code for this reason:
Signature rOate:`�•
�Qryweit0'verife by tlrivers license. No DHyersLicense No. >� �� a-
Verification of Ownership by (type of documen ,' 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 B, 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 e
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 WIII 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 we time during a repand 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 Mese Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materiels 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 ❑ No
.........._...................._.................__..........................._................................................_....................._..................._._._.................__................................................................................_........................_..............._...................
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication ayparmit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Uyes IJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
............. ................................................................................ _....................................................................... ................................_............................. ............................................. ................................................._...............................................
6 WIII any pan of the facilityto be constructed under this permit be wlthin 1000 feet from the outer boundaries of a school? ❑Ves ❑ No
(If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
.................... ...................... .............................................................................".-..........................................................-.............................................................................................. ........................................... ........................ ..................................
7 II a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this
.application, have allot. the . disclosures Described by,California .Health ,and _Safety Code. Section, 42303_ been. made? ,❑,Ves ❑,No
8 (II'�ach 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:
CERTIFlCA OF COMPLIANC ORIZAT10N OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is
correct. 1 ag e t ,complyi II stele law d city &dlnances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-describ DroZ/� r insp o6 n� purpos not t c py or allow occupancy of any building authorized by this Rermit�n i nal inspectiory
\/ I Salure Of Le al,Ov_r s)-' '; -,.- t3(i Date IYXy"
And/Or Authorized Applicant Data
CODE r. INSPECTION TYPE gAIE INTITAL5 COpE1 INSPECTION TYPE t1A1F ISL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final. 208 Final Plumbing
H.
200 Final Re-Roof v, 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
f.�
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.(GRADING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 330E 15TH ST
Suite:
Vicinity:
Parcel Nunmber. Zoning:
Applicant:
NIEMANN, DAVID
Address:
1273 STARLIT OR
Phone:
415-871-9945
LAGUNA BEACH, CA
Zip:
92651
Owner:
STIEFEL, LINDA L
Address
3359 VIA TIVOLI
Phone:
949-350-2867"
- ' COSTA MESA, CA %
Zip:
92626
Contractor:
DAVID KAIMI NIEMANN
Address:
1273 STARLIT DR -
Phone:
415-8p-9945
LAGUNA BEACH, CA
Vill
Zip:
92651
License: "
828096
Eng:
RON WINTERBURG
Address:
ORIGINAL ENGR
Phone:
949-650-5430
Zip: - License:
l,.
SCOPE OF PERMIT
Status: ISSUED
Applied: 12/222004
Issued: 02282007
ISSUED BY:
300 - -
FEE SUMMARY
Plan Check: $33.00 ' Calc Valuation: $35,000.00
$353.50 _
Permit: $72.00
Other: $0.00
$0.00
Inspection: $0.00
$0.00
1.
Total: $458.50
PLANNINGB ZONING-
NOTES: KUBOT_BJ 08/02/2005 PC EXTENSION GRANTED BY BDM. PERMIT TO
BE ISSUED BY 9/27/05.
1/18/06: ADVISED LINDA, PROP OWNER, TO FAX BDM LETTER
REQUESTING EXTENSION OF THIS ACTIVITY. SHE SAID PILING
APPROVED EXTENSION.
KENNE_S 10/13/2005 EXTENSION OF TIME FOR PLAN REVIEW
PERIOD GRANTED THROUGH DECEMBER 16, 2005 SUBJECT TO THE
nr •uuurn nnuumnrnu •nn nnvu ^r rrry rn
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, sucFi 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
2"6-46(6=)
y
DECLARATIONS
WORKERS' COMPENSATION DECLARATION: It +
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' compensafim 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:
Cagter:� Policy Number
7This section need not be completed H the permit is valued atone 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. 11 //
V_12
Apphicant � igna✓✓ ((Date: ) L4'- C"j'
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPL ER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE 1Etoo,ocol, 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:
hereby affirm that I am licensed underrovisions Chapter 9 (commencing with Section 7000) of Division 3 of.the Business d Professions Cada, and my license Is in full
forb"e`efd eneciriic� a O� _ �Class.a.
Contractors-Signature:^L M41w tDale! 2 2@• o
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, 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.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 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? ❑ 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.
..............._............................._...................................... _................................... __.................................. _...................... __ ............................ _.. ...................I........................................................._.................._.........._.
4 If an RMPP Is presently .required. has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [I No
I
.................................................................... ......................................................... _......................................................................................................................................................................................................................................... _......... _...
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a2 plication a ermlt for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? IJ Yes L) No
(Section 65850.2 of the California Government Code requires (hat the requested information be furnished on applications for non-residential building permits).
..........._._....................._................................................._........._..................__...............................-._.-....................._............................ ............................... ......................._...................._.............
6 Will any pert 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? ❑ Yes ❑ No
............................................................................................................................................................................................................................................................................................................................................................................................
B (If'ye9", attach certificate of compllanc6 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.
naturt 0fjajdtOwner(s) Date
�-
.rdfOr.Authorized-Appicanl— ' `--Date ---
CODE I. INSPECTION TYPE Brig iRITA CODE r INSPECTIONTYPE PATE I MA41 S
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/Retalning 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
R lV //VVY 1
SURVEYING
INC.
R\N MIEDEMA L.S. 4653
23016 LAKE FOREST DRIVE #A 409
LAGUNAJ-IILLS, CA 92653
(949) 858-224
(949)95R-1419\Fnw
ramsurveymg(cgcox.net
PAD CERTIFICATION:
May 3, 2007
TO: City of Costa Mesa, Inspection Dept
RE: 330 — 334 150s Street, Costa Mesa
To Whom it may concern,
I hereby approve the 3 building pads for this project.
I have checked the top of dirt in conformance with the approved
If you have any questions regarding this matter, please contact me.
Sincerely,
Miedy
FM IEQEMA O
p
NoAW ,P//
OF
ORANGE COAST
CIVIL ENGINEERING
May 4, 2009
City of Costa Mesa
Attn: Grading Inspector
PO Box 1200
Costa Mesa, CA 92626
Subject: Civil Engineer's Certification of Final Grading
Reference Project: Grading Permit No. G' o-o0oy>
Address: 33D E. ($ ST
Tract No.: — Lot No.
Permitted Yardage: Cut O C.Y.; Fill 3001 C.Y. C-rrn-.tL>
I hereby approve the final grading for the referenced project in accordance with my
responsibilities under the Orange County Grading and Excavation Code. Final
grading has been completed substantially in conformance with the approved grading
plan which includes: Completion of all engineering drainage devices and retaining
walls, setting of all monuments in accordance with the recorded tract map, location
and inclination of all manufactured slopes, and construction of earthen berms and
positive building pad drainage.
The volume of earth materials moved by cut and/or fill grading agrees with the
permitted yardage stated on the approved grading plan.
All structures constructed on property corners or property lines, and where
monumentation is not required, have been located in compliance with the approved
plot plan.
Michael M. Phillips, PE
R.C.E. C 68338 Exp. 9/30/09
5/4/09
Date
C 68338
EXP 9130109
(Seal)
5001 Birch Street, Newport Beach, CA 92660 * (949) 293-7194 * (866) 262-4897 Fax
mike@orangecoastcivileng.com
ORANGE COAST
CIVIL ENGINEERING
May 4, 2009
City of Costa Mesa
Attn: Grading Inspector
PO Box 1200
Costa Mesa, CA 92626
Subject: Civil Engineer's Certification of Final Grading
Reference Project: Grading Permit No. C-)09-00023
Address: 3777– 6, j STS S7
Tract No.: — Lot No.
Permitted Yardage: Cut O C.Y.; Fill 300 C. Y. GOT"��
I hereby approve the final grading for the referenced project in accordance with my
responsibilities under the Orange County Grading and Excavation Code. Final
grading has been completed substantially in conformance with the approved grading
plan which includes: Completion of all engineering drainage devices and retaining
walls, setting of all monuments in accordance with the recorded tract map, location
and inclination of all manufactured slopes, and construction of earthen berms and
positive building pad drainage.
The volume of earth materials moved by cut and/or fill grading agrees with the
permitted yardage stated on the approved grading plan.
All structures constructed on property corners or property lines, and where
monumentation is not required, have been located in compliance with the approved
plot plan.
C 68338 a
EXP 9130109 6
/� �� 5/4/09
Michael M. Phillips, PE Date (Seal)
R.C.E. C 68338 Exp. 9/30/09
5001 Birch Street, Newport Beach, CA 92660 * (949) 293-7194 * (866) 262-4897 Fax
mike@orangecoasteivileng.com
ORANGE COAST
CIVIL ENGINEERING
May 4, 2009
City of Costa Mesa
Attn: Grading Inspector
PO Box 1200
Costa Mesa, CA 92626
Subject: Civil Engineer's Certification of Final Grading
Reference Project: Grading Permit No. G)O_( -ono-z3
Address: 33t ( E . I t:�'W '&T-
Tract
TTract No.: Lot No. --
Permitted Yardage: Cut (_C.Y.; Fill '30o C.Y. C nq,—It >
I hereby approve the final grading for the referenced project in accordance with my
responsibilities under the Orange County Grading and Excavation Code. Final
grading has been completed substantially in conformance with the approved grading
plan which includes: Completion of all engineering drainage devices and retaining
walls, setting of all monuments in accordance with the recorded tract map, location
and inclination of all manufactured slopes, and construction of earthen berms and
positive building pad drainage.
The volume of earth materials moved by cut and/or fill grading agrees with the
permitted yardage stated on the approved grading plan.
All structures constructed on property corners or property lines, and where
monumentation is not required, have been located in compliance with the approved
plot plan.
Michael M. Phillips, PE
R.C.E. C 68338 Exp. 9/30/09
5/4/09
Date
C 68338
EXP 9130109
(Seal)
5001 Birch Street, Newport Beach, CA 92660 * (949) 293-7194 * (866) 262-4897 Fax
mike@orangecoastcivileng.com
INSULATION CERTIFICATE IC -1
Site Address Permit Number
605-06019 a-
370 332 33 6 /5'N ST-, COSTA Mt5S�- COSTA Mb�tl
Number and StreetCity
P-RANG�
County Subdivision Lot Number
Description of Installation
I. ROOF
Material /Cl en �0�6 17,
Brand Name TAMf!O
Thickness (inchesj, 55nzi6
Thermal Resistance (R -Value)
2. CEILING
Batt or Blanket Type
Brand Name
Thickness (inches) ip t
Thermal Resistance (R -Value) R 1 q
Loose Fill Type
Brand 066CfAinli�D
Contractor's min installed weight/ft' lb
Minimum thickness inches
Manufacturer's installed weight per square foot to achieve
Thermal Resistance (R -Value)
3. EXTERIOR WALL
Frame Type WOOD
A. Cavity Insulation
Material ri j3 ek-&ASS
Brand Name (6-P—TA/Af7Ei"D
Thickness (inches)
Thermal Resistance (R -Value) ,P-/3
B . Exterior Foam Sheathing
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
4. RAISED FLOOR
Material NIA
Brand Name
Thickness hes)
Thermal Resistance (R -Value)
5. SLAB FLOOR/PERIMETER
Material 121G/D EDAM
Brand Name FCAMGLt"p1
Thickness (inches) -2
Thermal Resistance (R -Value)
Perimeter Insulation Depth (inches)
6. FOUNDATION WALL
Material WfAi j FVA-/y
_
Brand NamerOAMt{Uq--
Thickness (inches) 2''
Thermal Resistance (R -Value) —/O
Declaration '
1 hereby certify that the above insulation was installed in the building at the above location in conformance with the current
Energy Efficiency Standards for residential buildings (Title 24, Part 6, California Code of Regulations) as indicated on the
Certificate of Compliance, where applicable. .
I to al/ud"/ a�oy Mneme
Item #s Signature, Date Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
Item #s Signature, Date Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
Item #s Signature, Date Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
Compliance Forms August 2001 A-36
INSULATION CERTIFICATE
IC -1
Site Address
Permit Number 6Q5-Ct5rV6
1579 S7,,
C0S7A M.5-4 COSTA M�Sd
Number and Streetcity
_O,eAN�
County Subdivision Lot Number
Description of Installation
I. ROOF
Material /C"Len 3VIZ K Zt 4
Brand Name TAM f O
Thickness (inches) 15�4tLL
Thermal Resistance (R -Value)
2. CEILING
Batt or Blanket Type
Brand Name
Thickness (inches)(P�
Thermal Resistance (R -Value) R- I q
Loose Fill Type
Brand afwgTAin(Te—�6D
Contractor's min installed weight/ft'
Ib Minimum thickness inches
Manufacturer's installed weight per square
foot to achieve Thermal Resistance (R -Value)
3. EXTERIOR WALL
Frame Type WOOD
A. Cavity Insulation
Material (%/ 6a&tASS
Brand Name CE,2,77i /1117E1�D
Thickness (inches)
Thermal Resistance (R -Value) A9-/3
B. Exterior Foam Sheathing
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
4. RAISED FLOOR
Material N/A
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
5. SLAB FLOOR/PERIMETER
Material 1216iD f:�o1aM
Brand Name FOAMU.LA�
Thickness (inches) .2"
Thermal Resistance (R -Value)
Perimeter Insulation Depth (inches)
6. FOUNDATION WALL
Material �P/r(b fp/}-iy
Brand Name t OANjU
Thickness (inches) 2''
Thermal Resistance (R -Value) -/0
Declaration
1 hereby certify that the above insulation was installed in the building at the above location in conformance with the current
Energy Efficiency Standards for residential buildings (Title 24, Part 6, California Code of Regulations) as indicated on the
Certificate of Compliance, where applicable.
h46f�dianure�l/�/a��oy pion
Item #s Signature, Date '�J Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
Item #s
Signature, Date
Signature, Date
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
Compliance Forms August 2001 A-36
CITY OF COSTA MESA Aw
0 pMFq BUILDING DIVISION
i` 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.00sla-mesa.ca.us
F
FOR INSPECTIONS CALL: (714) 754.5626
PERMIT NUMBER: E09-00082
PERMIT TYPE ELEC STATUS: ISSUED
APN: TPNO09010 DATE ISSUED: 04/08/2009
ISSUED BY: RMD
JOB ADDRESS: 330 A E 15TH ST CM Suite/Unit: A
Vicinity: COMMON AREA
SCOPE OF WORK: ELECTRICAL PERMIT FOR THE INSTALLATION OF A 200A SERVICE PANEL LOCATED IN THE COMMON AREA FOR 3
DETACHED SFD.
OWNER:
15TH STREET LLC
PHONE:
949-292-6000
APPLICANT:
GONZALEZ, CYNTHIA
PHONE:
714-330-6435
CONTRACTOR: OWNER -BUILDER
Address:
Unit: PHONE:
City/State:
ZipCode:
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee:
$0.00
Electrical Permit Fee:
$54.00
Reinspection Fee
$0.00
TOTAL FEES
$54.00
Address: 20371 IRVINE AV Unit:SUITE 210
City/State/Zip: SANTA ANA, CA
Address: 21017 HAWIIAN AVE Unit:
City/State/zZip: LAKEWOOD, CA
License No. 000000
CELL:
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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
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.
CODE r. INSPECTION TYPE DATE INTITIALS CODEC INSPEC11011 TYPE DAtE INTMALS
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/Retaming 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/Oocupancy
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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:
(Thm sec(rn need not be oomp'efed if the permit is valued atone hundred sonars (3100) or less.)
Policy
Number:
'Ell' 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 forth tlith comply with these provisions.
�/ O
Applies s �gnato
WARNING: FAILURE TO SE u RE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($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. #
Contractor's Signature
Class #
CONSTRUCTION LENDING AGENCY:
❑ 1 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:
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. 70315,
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).):
-Q<1; 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.).
Q 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.).
Owner ID verified by driver's • license. 113 es ❑ No
Driver's -License No. Expires:, -7 ZDI
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, The 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.
Applicants 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 ❑ 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
of 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? ❑ 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 permit for such construction
or modification from the South Coast Air Quality Management District or from
any other air pollution control district or agency? ❑ 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? ❑ 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? ❑ 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 slate laws and
city ordinances regarding Hazardous Materials and Emissions.
Signature
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury that I have read this application and state that
�] • 1 am exempt under sec. the information given is correct. I agree to comply with all stale laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: 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
�raj authorized by this permit until final inspection.
4'r6/O� /Signature /off Le1gal/Ow/ner(s) /I 'Date
3057-06 (3le7) Anoror Aulfleflzp Appliwol Died
CITY OF COSTA MESA
Oma" MFS,p BUILDING DIVISION
iA 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
t
y�a�eM' FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER: P09-00052
PERMIT TYPE PLUM STATUS: ISSUED
APN: TPNO09010 DATE ISSUED: 04/08/2009
ISSUED BY: RMD
JOB ADDRESS: 330 A E 15TH ST CM Suite/Unit: A
Vicinity: COMMON AREA
SCOPE OF WORK: PLUMBING PERMIT FOR THE INSTALLATION OF NEW WATER SERVICE LOCATED IN THE COMMON
AREA FOR 3 DETACHED SFD.
OWNER:
15TH STREET LLC
PHONE:
949-292-6000'
APPLICANT:
GONLALEZ, CYNTHIA
PHONE:
714-330-6435
CONTRACTOR: OWNER -BUILDER
Address:
City/State:
ARCHITECT:
ENGINEER:
ZipCode:
Address:
City/State/Zip:
Address:
City/State/zZip:
License No.
License No.
20371 IRVINE AV SUITE 210
SANTA ANA, CA
21017 HAWIIAN AVE
LAKEWOOD, CA
License No. 000000
PHONE:
CELL:
PLUMBING PERMIT FEE SUMMARY
PLAN CHECK FEE: $0.00
PERMIT FEE: $33.30
TOTAL FEES: $33.30
PHONE:
PHONE:
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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
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.
CODE / INSPECTION TYPETYPE DATE IN S CODE/ INSPECTION TYPE DAM INTMALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical c1,
1266 Pool Spa Final 206 Final Plumbing
200 Final Re -Roof 210 Final Electnwl
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
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:
Cartier:
(Thu section readnext be mnrolded d the permn is valued at one hundred oci (5100) a fess )
Policy Number:
B-11I.certify that in the performance Of the work for which this permit is
issued, 1 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 Coe, 1 shall forthwith comply with these provisions.
Aper rn a ! r Dat Q
WARNING: FAILU O RE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
(5700,000), 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:
❑ 1 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:
Date
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penally 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.).
Owner ID verified by driver's license. Yes [3 No h
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:
❑ 1 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.
Applicants Signature
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 ❑ No
(Section 25505 of the Califomia Health and Safety Code requires, with some
exceptions, that a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas
at standard temperature and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration forth 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? ❑ 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 permit for such construction
or modification from the South Coast Air Quality Management District or from
any other air pollution control district or agency? ❑ 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? ❑ 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? ❑ 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
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
city ordinances regarding Hazardous Materials and Emissions.
LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and
Professions Code: The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon, and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s) license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
❑ I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: 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.
(] Sign awre Legal 0.cr(s) Data
Signal re . Dat
3057-46(W07) AncUcT Authonze App icanl ales ..
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
MECHANICAL PERMIT
.lob Address: 330 E 15TH ST
Suite No
Vicinity:
Parcel Number: 42531101
Applicant:
DAVID KAIMI NIEMANN
Address:
1273 STARLIT OR ,
1 -' -
LAGUNA"BEACH, CA ,
Owner:
/STIEFEL; LINDA_ L,,
Address
" 3359 VIA TIVOLI,
i
Evaporative Cooler
"
COSTA MESA, CA "
Contractor: DAVID KAIMI NIEMANN
Address:- 1273 STARLIT OR
LAGUNA BEACH, CA
REVISED 06-07-07: ADD RADIANT
NEW 1,884 S.F. 2 STORY S.F.D.
Status: ISSUED
Applied: 05/30/2007
Issued: 05/30/2007
ISSUED BY:
Phone: 415-871-9945 "
Zip: 92651 "
Phone: 949-350-2867
Zip: 92626
Phone: 415-871-9945
Zip: 92651
License: 828096
MECHANICAL INCLUDES: 1 REPAIR/ALT COOLING/HEAT, i FAU < 100K BTU, 5 VENT FANS,
1 GAS PIPING, 1 FACTORY FIREPLACE, 1 HOOD W/MECH EXHAUST, 1
COMPRESSOR/ABSORPTION SYSTEM 3-]5 HP.REF: B05-00011
FEE SUMMARY
Quantity
ISSUE FEE
Inst FAU <100 k BTU
Inst FAU >100 k BTU
Repair/ Alt Cooling/Heat
Inst / Rep. Recess Wall Htr
Refrig Sys <100 k BTU
Refrig Sys >100 k BTU
Gas Piping
Factory Fireplace
Hood w/Mech Exhaust
VAV Box
Vent Fan / Single Duct
Appliance
Fire Dampers
Smoke Dampers '
Inst or Relocate Appl Vent
Air Handlers < 10000cfm.
Air Handlers > 10000cfm
Floor Furnace
Floor or Suspend Heater
$23.50
Repair/ Alt Absorbtion Unit
$14.80
1 -' -
Repair l Alt Refrigeration Unit
$0.00
0
Ventillation System
$13.70
1
Evaporative Cooler
$0.00
0
Commercial Incinerator ,
$0.00
0
Domestic Incinerator
$0.00
0
Compressors / Absorption Systems
$6.15
-
1..
", Upto3 hp/100k BTU
$10.65
1 '� '�- '-'
3 -To -15 hp 1500 k BTU
$10.65
1 -,
15 To 30 hp/ 1,000 k BTU
$0.00
0 ..
"; 30 To 50 hp 71,750 k BTU
$3625-
5 ,:
Over 50 hp / Over 1;750 -BTU
'-$0.00
0 -
Boilers ".
$0.00
0
Up to -3 hp
$0.00
0
3 To 15 hp
$0.000
°
- 15 to 30 hp
$0.00
,�
0 -
30 to 50 hp
$0.00
0
Over 50 hp "
$0.00
", 0 -
Other Mechanical Fee -
$0.00
0 -
Investigation Fee -
-Plan Check Fee -
-
Reinspection Fee
-
TOTAL CALCULATED FEES
COMMENTS / SPECIAL CONDITIONS
Quantity
50.00 0
$0.00 0
$0.00 0
S0.00 0
$0.00 0
50.00 0
$0.00 - 0
$0.00 0
$0.00 '0
$0.00 .0
$0.00 ; 0
$0.00 0
$27.15 1
$0.00 0
$0.00 0
$0.00 0
$0.00
50.00
$0.00
$152.65
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 all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
permit.
FOR INSPECTIONS CALL: (714) 754-5626 U
11
246648 (6100)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensalion, 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.
L°
My workers' compensation Insurance carder and policy number are: _
Carrier: Policy Number:
_(`ThiIs section need not be completed if the permit is valued of one hundred dollars ($100) or less.)
[q I certify that in the Porto ance oft ork 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 Ilfomla, a d me hat If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply With these provi io ss��
(Applicant Signature: Data:
(WARNING: FAILURE TO SECURE ORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBIECT 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 NOS OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed ur ptvls(eq;- f Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prot scions Code, my license is in full
-force and effect. Lic. x UL'G V"� U CClass a r C.— l
-Contractors Signature: -Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permil is issued. (Sec. 3097, Civil Code).
Lenders Name: Lender's Address:
Signature: Dale:
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).):
❑ 1, 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 t0 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 appy to an owner of propery who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 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, All 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 ❑ 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 torn 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)?
El Yes 13
(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 ❑ No
..................................................................................... ..... ................... ........ ..... ..................... .............................................................................. ...................................................................... ...................... _.................................................................
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication apparmit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes u No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
fi Will any part of the facility to be constructed under this permit be within 10001ee1 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 II a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? [I 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: Dale:
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 inspectionrposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
u
S' na re 1 L el Owner(s) Date
6-"�
L A Auto ed Applicant r -Date -
CODE A. INSPECTION TYP1NTITI9L5 CODE( INSPECTION TYPE MM
1616 Fixed System Final Fire Prevention 206 Final Mechanical LA (p A V1
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
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
MECHANICAL PERMIT
.lob Address: 330 E 15TH ST
Suite No
Vicinity:
Parcel Number: 42531101
Applicant: DAVID KAIMI NIEMANN.
Address: 1273 STARLIT DR
Phone: 415-871-9945
LAGUNA BEACH, CA Zip: 92651
Owner- STIEFEL, LINDA L
Address: 3359 VIA TIVOLI
Phone: 949-350-2867
COSTA MESA, CA Zip: 92626
Contractor: DAVID KAIMI NIEMANN
Address: 1273 STARLIT DR
Phone: 415-871-9945
LAGUNA BEACH, CA Zip: 92651
License: 828096
SCOPE OF PERMIT
NEW 1,884 S.F. 2 STORY S.F.D.
Status: ISSUED
Applied: 05/30/2007
Issued: 05/30/2 0
ISSUED BY: 4
MECHANICAL INCLUDES: 1 REPAIR/ALT COOLING/HEAT, 1 FAU < 100K BTU, 5 VENT FANS,
1 GAS PIPING, 1 FACTORY FIREPLACE, 1 HOOD W/MECH EXHAUST, 1
COMPRESSOR/ABSORPTION SYSTEM 3-15 HP. Iter 67�. am/t
FEE SUMMARY
Quantity
Repair/ All Absorbtion Unit
$0.00
Quantity
ISSUE FEE
$23.50
0
Inst FAU<100 k BTU
$14.80
1
Inst FAU >100 k BTU
$0.00
0
Repair/ Alt Cooling/Heat
$13.70
1
Inst / Rep. Recess Wall Htr
$0.00
0
Refrig Sys <100 k BTU
$0.00
0
Refrig Sys > 100 k BTU
50.00
0
Gas Piping
$6.15
1
Factory Fireplace
S10.65
1
Hood w/Mech Exhaust
$10.65
1
VAV Box
$0.00
0
Vent Fan / Single Duct
536.25
5
Appliance
$0.00
0
Fire Dampers
$0.00
0
Smoke Dampers
$0.00
0
Inst or Relocate Appl Vent
$0.00
0
Air Handlers < 10000cfm
$0.00
0
Air Handlers> 10000cfm
$0.00
0
Floor Furnace
50.00
0
Floor or Suspend Heater
$0.00
0
FEE SUMMARY
Quantity
Repair/ All Absorbtion Unit
$0.00
0
Repair / Alt Refrigeration Unit
$0.00
0
Ventillation System
$0.00
0
Evaporative Cooler
$0.00
0
Commercial Incinerator
$0.00
0
Domestic Incinerator
50.00
0
Compressors /Absorption Systems
Up to 3 hip/100k BTU
$0.00
0
3 To 15 hp/500k BTU
S0.00
0
15 To 30 hp / 1,000 k BTU
$0.00
0
30 To 50 hp 11,750 k BTU
$0.00
0
Over 50 hp / Over 1,750 BTU
$0.00
0
Boilers
Up to 3 hp
50.00
0
3 To 15 hp
S27.15
1
15 to 30 hp
$0.00
0
30 to 50 hp
$0.00
0
Over 50 hp
$0.00
0
Other Mechanical Fee
Investigation Fee
$0.00
Plan Check Fee
$0.00
Reinspection Fee
$0.00
TOTAL CALCULATED FEES
$142.85
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and-ielated
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 suspenc! r abandoned
for a period of 180 days.
Itu
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
2446.66(6=)
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the fallowing 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.
Lhave 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 carder and policy number are:
Rite r�Po6cy Number:—,
?Ths section need not be comp/eted i/ the permit is valued of one hundred dollars ($100) or less.) —"
❑I I certify that In the performance of the work or which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers'
V compensation laws of California, and agree it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these isio s.
WP11W—nt'Signature;_ VI/ln—�- ate:__ ? 15 Ao- 0�—
WARNING: FAILURE TO SECURE WORKERS' COMPENS TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF ODMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirn that 1 am licensed underryrovi Ions of hapter 9 (commencing with Section 7000) of Division 3 of the-13usiness.and_Professions Cade, and my license is in full
.fo Ger"`,and,eHad..uc— s. ��Yi1 Cf� 7 _ iasaw 1� G 15
Contractors 6ignature: - - .�— (Da .�-�- 'C;7 • 4 0 • 0.Y
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 wunty 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).):
❑ 1, 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.).
❑ 1 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, Le. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 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 -lore than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title B, 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 ❑ 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 theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutety, hazardous materials)?
❑ Yes ❑ we
(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.
................................................................................................................................ .............................. .............................................................................................................. I.............................. I.................... .................................... I..................
4 If en RMPP Is Dresently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
.......................................................................................... .................................. .... .... ........................... ................................... .................................................................................. ........................... .... ....... .................................................................
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plicatlon a ppermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes U No
(Section 65650.2 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).
F.W. 7 II a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
................................................ ..................... ......................... .... ................................... .... ........................ .......................................................................... ................................................................................................................................ I................
e (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 wmply 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 tate laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described Pr any for insp coon purposes. I agree not to Occupy or allow Occupancy of any building authorized by this permit until final inspection.
Sign re OI Legal Owns ate
CODE Ii. INSPECTION INTITIALS CODE I INSPECTION TYPE g9g INTITA$
1616 Fixed System Final a Preventio 206 Final Mechanical
1266 Pool Spa Final 20 Final Plumbing
200 Final Re-Roof 0 Final Electric
201 Final Blwk/Relaining W 212 nal F ventlon
202 Final Factory Fire Place ' - Fin Plan ' Approval
203 Final Sign trial Site
204 Final Demolition 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
PO4-00576
PLUMBING PERMIT
Job Address:
330 E 15TH ST Status: FINALED
Suite No
Applied: 08/17/2004
Issued: 08/18/2004
Vicinity:
ISSUED BY: 51 k.
Parcel Nunmber:
42531101
Applicant:
STIEFEL, LINDA L
Address:
3359 VIA TIVOLI
Phone: 949-350-2867
COSTA MESA, CA Zip: 92626
OP
Owner: STIEFEL, LINDA L
Address 3359 VIA TIVOLI
Phone: 949-350-2867
COSTA MESA, CA Zip: 92626
Contractor:
Address:
Phone:
Zip:
License:
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 vold 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) 7545626
30646 (6100)
SCOPE OF PERMIT
DEMOLISH 1,378 S.F. S.F.D. CAP ELECTRICAL AND SEWER CONNECTION. REF.: B04-01455
APPLICANT WILL CONTACT A.Q.M.D. PRIOR TO DEMOLITION.
FEE SUMMARY
AMT QTY AMT
QTY
AMT
QTY
ISSUE FEE
$23.50 Laundry Tub / Washer
$0.00 0
Sump Pump
$0.00
0
Backflow irrigation
$0.00 0 Landscape Irrigation
$0.00 0
Swimming Pool
$0.00
0
Backflow Preventer
$0.00 0 P -Trap
$0.00 0
Trap Primer
$0.00
0
Bathtub
$0.00 0 Pressure Regulator
$0.00 0
Urinal
$0.00
0
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 vold 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) 7545626
30646 (6100)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION: '
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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 pernit Is Issued.
❑ 1 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 workerscompensation Insurance carder and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit is valued atone hundred dollars ($100) or less.)
❑ 1 certify that in the performance of the work for which this permit is issued, 1 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' componsatlon provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING: FAILURE TO SECURE WORKERSCOMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES 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 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. It Class N
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 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 99tillik that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county whi q "it to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit
to file a signed staterT TI GIs nsed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and ofesa a that h r she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjeclsitle �I- '1 pe more than five hundred dollars ($500).):
❑ 1, asurvner p my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec.
7044,`B siness a rofessions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work
himseN 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 wi 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.). '
❑ 1, 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.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires:
Verification of Ownership by (type of document, Le. - 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, wII1 be made in connection with work authorized by this
permit, and that no building structure, scaffolding, lalsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Cade).
❑ 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 candy 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 2DO cubic feet of compressed gas at standard temperature and pressure).
..........................................................................................................................................................................................................................................................................................................................................................................................
2 Does or will the applicant or presort or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ON o
(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).
............................................... I.................. _................................................ ............... ... .................................. .... .......................... ........................................................................... _............................. ........._.................................. ..........
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 en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No
........................................................... ......................... ...................................... ...... ............................................................ ...................................................................................................... ............_................
..........................................................
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication apperrnil for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished cm applications for non-residential building permits).
................................__..................__.............................__......................................_...............____........._.........._._._..._..................._..__........_............................_........_._..._..............._............_.._......................_..._..........
6 Will any part of t h a 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 Cade).
............................. ....................... ........................... ................................................................... —._......................... _._................................... _._....-........................................ _._._.._................................ ............ _............... .....
7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
_.........................____....... ................................................... ....... .... ....................... .............._.............................. ............... ........ .............................. .............. _.......................................... _.............. _................. _........
8 (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 cerrecl. 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. 1 agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE f. INSPEcnoN TYPE PAU INMIALS CODE# INSPECTION TYPE DATE
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing ie
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 BuildingrOocupancy
Clarifier System
$0.00
0
Process Piping (per 10 ft)
$0.00
0
Vacuum
Brkr Bkflow(1-4)
$0.00
0
Connect (Ice,Soda,etc)
$0.00
0
Receptors $0.00
0
Vacuum Brkr BkFlow(5+)
$0.00
0
Dental Units
$0.00
0
Septic Tank $0.00
0
Wash Basin
$0.00
0
Dishwasher
$0.00
0
Sewer Cap for Demo $9.80
1
Wash Basin Set
$0.00
0
Drain, Floor
$0.00
0
Sewer Connect $0.00
0
Waste and Vent System
$0.00
0
Drain, Rainwater
$0.00
0
Sewer Private Line $0.00
0
Water Closet (Toilet)
$0.00
0
Drain, Roof
$0.00
0
Shower $0.00
0
Water Heater / vent
$0.00
0
Drinking Fountain
$0.00
0
Sink, bar
$0.00
0
Water
Piping (Inst or Rep.)
$0.00
0
Expansion Tank
$0.00
0
Sink, commercial
$0.00
0
Water
Re -pipe
$0.00
0
Gas Earthquake Valve
$0.00
0
Sink, Floor
$0.00
0
Water
Service
$0.00
0
Gas (1-4 outlets)
$0.00
0
Sink, kitchen
$0.00
0
Water
Softener
$0.00
0
Gas (Over 4 outlets)
$0.00
0
Sink, service/mop
$0.00
0
OTHER
$0.00
Gas Repipe
$0.00
0
Spa (private) $0.00
0
VIOLATION
$0.00
Gas Service
$0.00
0
Spa (public) $0.00
0
PLAN CHECK
$0.00
Interceptors (Grease, Oil)
$0.00
0
REINSPECTION
$0.00
0
Interceptors (Sand Auto)
$0.00
0
TOTAL
CALCULATED FEES: $33.30
COMMENTS / SPECIAL CONDITIONS
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address: 330 E 15TH ST
Suite No
Vicinity:
Parcel Nunmber: 42531101
Applicant: STIEFEL, LINDA L
Address: 3359 VIA TIVOLI
COSTA MESA, CA
Owner: STIEFEL, LINDA L
Address 3359 VIA TIVOLI
Contractor:
Address:
COSTA MESA, CA
Status:
FINALED
Applied:
08/17/2004
Issued:
08/18/2004
ISSUED BY: Z
Phone: 949-350-2867
Zip 92626
COP
Phone: 949-350-2867
Zip: 92626 )P
Phone:
Zip:
License:
SCOPE OF PERMIT
DEMOLISH 1,378 S.F. S.F.D. CAP ELECTRICAL AND SEWER CONNECTION. REF.: B04-01455
APPLICANT WILL CONTACT A.Q.M.D. PRIOR TO DEMOLITION.
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
2"a (aw)
FEE SUMMARY
Quantity
Quantity
ISSUB FEE
$23.50
Temp Dist System / Lighting
$0.00
0
Temp service test
50.00
Busway /100 It
S0.00
0
Res. a/c package
$0.00
Standing Section
$0.00
0
New Res (1-2 units)
$0.00
0
Misc Electrical Equipment
$0.00
0
New Res (3+units)
$0.00
0
Transformers up to 1 kva/kw
$0.00
0
Pool / Spa
$0.00
0
................ up to 10 kva/kw
$0.00
0
Lighting Fixts
$0.00
0
.................up to 50 kva/kw
$0.00
0
Recept Outlets
$0.00
0
.................up to 100 kva/kw
$0.00
0
Switches
$0.00
0
..................over 100 kva/kw
$0.00
0
Non Res Appl
$0.00
0
Low Voltage Equipment
$0.00
0
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
2"a (aw)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workerscompensation, 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.)
❑ 1 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' compensatlon provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37DS OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full
force and effect. Lie. # Class #
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affiml 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 herebyaffirm that and na ih am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following r n
Baso (Sec. 7031.5, Business and Processions
Code: Any city oryyyyyyyyyyyyu h� qui . a perm"it110 construct, eller, Improve, tlemolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit
to file a sig sta nt q{ fie�ar she is I�M.ensed pursuant to the provisions of the Contractors License Lew (Chapter 9 (commencing with Section 7W0) of Division 3 of the
Business a t>s,tliel ha 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 e I ant to e c e eltyTof not more than five hundred dollars ($500).):
❑ I, as owns the property, or my employees with wages es their sole compensation, WILL DO THE WORK, end the structure Is not inlendetl or offered for sale (Sac.
7044, Busi ss end Professions Cotle: The Contractors License Lew tloes not apply to en owner of property who builds or Improves thereon, antl who tloes 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
Cade: 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 Drivers License No. Expires:
Verification of Ownership by (type of document, Le. - 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, ialsework, 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 Indusmal 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 ❑ 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 .... ..... ....... ........................... ___................................ _.._........... ....................................... _.......................................... _.......................................__...
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).
......................................................................................................"..................................................................................................................................................................................................................,......................................................I..........
3 Does or will ENO 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 en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No
................................... .... _......................._......................_.............._.........................._...................._""...............................___....................................""...__..._.......................... —......... _................. __............. _.............
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication appemit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes L_I 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 peri It be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(II yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
. ......................... _................................................................................................................. __............................ _._...................................... .................................................... ............. __............... -..................................................................
7 If appermit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which Is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
......................................................................................... _-...............................................................................................................................................................................................................................................................................................
8 (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 AUTHORLZA71ON 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) Date
And/Or Authorized Applicant Date
CODE I. INSPECTION TYPE PATE INTITA14 CODE# INSPECTION TYPE Lr/_I.F INITTLELS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
i� .�
200 Final Re -Roof 210 Final Electrical J
201 Final Block/Retalning 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
Res Appl
$0.00
0
Low Volt Wiring System / Ckt
$0.00
Service to 200a
$0.00
0
Misc. Conduit
$0.00
Service to 1000a
$0.00
0
Misc. Conductor
$0.00
Service over 1000a
$0.00
0
Circus ( gen or ride)
$0.00
Motors to 1hp
$0.00
0
Circus (mech ride or lights)
$0.00
Motors to 10hp
$0.00
0
Christmas Tree Stand
$0.00
Motors to 50hp
$0.00
0
Fireworks Stand
$0.00
Motors to 100hp
$0.00
0
Other Electrical Fee
$9.80
Motors over 100hp
$0.00
0
drops $0.00
0 Investigation
Fee
$0.00
Sub panel to 200a
$0.00
0
Plan Check Fee
$0.00
Pole Light Pkg
$0.00
0
Reinspection Fee
S0.00
Sign Circuits
$0.00
0
Temp Pwr Pole
$0.00
0
TOTAL CALCULATED FEES
$33.30
Intermed Pole
$0.00
0
COMMENTS / SPECIAL CONDITIONS
0
0
0
0
0
0
0
Communication
r
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 330 E 15TH ST
Suite:
Vicinity:
Parcel Number:
42531101
Zoning:
08/17/2004
Applicant:
STIEFEL, LINDA L
Calc Valuation: 83,450.00
Address:
3359 VIA TIVOLI
Claim Valuation: 83,450.00
SMTP Res:
$0.50
Phone:
949-350-2867
SMTP Com:
COSTA MESA, CA
Zip:
92626
Owner:
STIEFEL, LINDA L
Address
3359 VIA TIVOLI
,
Total:
$97.75
Phone:
949-350-2867
COSTA MESA, CA
Zip:
92626
Contractor:
Address:
Phone:
Zip: License:
Arch :
Address:
Eng:
Address:
Status:
ISSUED
Applied:
08/17/2004
Issued:
08/18/2004
i
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
DEMOLISH 1,378 S.F. S.F.D.
APPLICANT WILL CONTACT A.Q.M.D. PRIOR TO DEMOLITION.
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. e INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in t this permit.
FOR INSPECTIONS CALL: (714) 754-5626
244646 (6100)
FEE SUMMARY
Plan Check:
$0.00
Calc Valuation: 83,450.00
Permit:
$97.25
Claim Valuation: 83,450.00
SMTP Res:
$0.50
SMTP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
,
Total:
$97.75
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
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. e INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in t this permit.
FOR INSPECTIONS CALL: (714) 754-5626
244646 (6100)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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 perfornance of the
work for which this permit Is issued.
❑ 1 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 a ction need not be completed 11 the permit is valued at one hundred dollars ($100) or less.)
;; I certity that In the p�do!r nce of the work 7m J.dpob.1niatosue
is d, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws Ot6611fomla, endegree a54 ilFFs ubJ t to the workers' compensation provisions of Section 3700 of the Labor Code, I shell forthwith
compensati these' i ions.
Applicant Signa re: Date:
WARNING: FA ILU SEC EWORKERS'COM E -IS UNLA AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMP TION, 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. If Class N
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 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
Cale: 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: cont ctore-LICenso, s not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors)
license ursu Ilb the Contra tors LI a Law&).
❑/1•am'ex d se sinew and Professions Code for this reason:
SI nature:
Own Ified. y d 's license. Ves ❑ No Drivers License No. Expires:
Verification of Ownership by (type o oc t, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
t -it oreby cppritty that no excavation five (5) or more feet in depth into which a person is required tend, will be made in Connection with work authorized by this
permit, and that no building sim e, scaffolding, fats", or demolition or dismantling there_,, w I be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title B, Calif mile Adminl5 eti a Code).
❑ As owe ul r, I.wdl-50 em an o do work w ch would require a perdiit from the Di ision of Industnel Safety, noted aboveaunlesss person hes e
erml ttrd_ uc 4 Iron the Sion. /
i2tre: Date:
Division o1 dust al ety Permit u r:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 WIII 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 tiled with the Costa Mesa Fire Department by every
business which has at any one time during a reponed year a quantity of hazardous materials equal to or greater than a weight of SDO 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? ❑Ves ❑ 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 o, 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
...................................................................................................................... ..................................... -....................................................................................................... ............. ............................................................................
3 Does or will theappplicant 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 en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No
.................................................... ............ .......................... ................................................... ... ...................... ........-......................... ...................... ......................... ............................................................ ................... ................................ ......
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication ayPermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes U No
(Section 65650.2 o, the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
..............._......................__.........................._._.........._..............................................._.__......................._._................_._..._..........."_'—"'..............................................._._.................___................_..............._............—
6 Will any pan o, the laciltry 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 a permit from the South Coast Air Quality Management District or other air pollution control distract or agency is required for the work which is the subject of this
applicalion, have all of the disclosures prescribed by California Health and Safety Cade Section 42303 been made? ❑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 slate laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFATE O COMPLIANCE AND AUTHORIZATION OF ENTRY: I certity under penalty of perjury that I have read this application and state that the information given is
correct. o comply with tale laws d city ordinances relating to buliding construction, and authorize representatives of the City of Costa Mesa to enter upon the
'above-d 6 d property a Billion p s. I agr no Occupy or allow occupancy of any building authorized by this p,7 until fi I'nspeclion.
Signature
Legal O 'er(s) Date '
And/Or Authorized Applicant Date
CODE 1. INSPECTION TYPE 2AU INTRIAL CODE INSPECTION TYPE g>,IE 1)4117111LS
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 Y 222 Final Site
204 Final Demolition :l''Q� 250 Final Building/Occupancy
-'
I
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 330E 15TH ST
Suite:
Vicinity: DETACHED GARAGE & APT
Parcel Number:
42531101
Zoning:
Applicant:
STIEFEL, LINDA L
- Eng:
Address:
3359 VIA TIVOLI "
Address:
Phone:
Phone:
949-350-2867
Zip:
'
COSTA MESA, CA
Zip:
92626
Owner:
STIEFEL, LINDA L
SCOPE OF PERMIT
Address
3359 VIA TIVOLI
APPLICANT WILL CONTACT A.O.M.D. PRIOR TO DEMOLITION. -
"
Phone:
949-350-2867
COSTA MESA, CA
Zip:
92626
Contractor:
Address:
Phone:
ISSUED BY:
Status: ISSUED
Applied: 08/17/2004
Issued: 08/18/2004
<�A��'/
Zip:
License:
Arch :
- Eng:
Address:
-
Address:
Phone:
Phone:
Zip:
'
License:
License:
SCOPE OF PERMIT
DEMOLISH 342 S.F. DETACHED GARAGE AND 234
S.F. APARTMENT U -
APPLICANT WILL CONTACT A.O.M.D. PRIOR TO DEMOLITION. -
FEE SUMMARY
Plan Check: $0.00
Calc Valuation: $3,450.00
Permit: $97.25
Claim Valuation: $3,450.00
SMIP Res: $0.50
SMIP Com: $0.00
-.� . Other: $0.00
Inspection: $0.00
i
Total: $97.75
R
r
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 0-01
PARKING Existing: 0
Required:
0 Proposed: 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
ta4646 t&001
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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.
❑ 1 have and will maintain workers' compensation insurance, as required by swim 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
My workers' compensallon Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed it the permit isvaluedat one hundred dollars ($100) or less.)
0:51 certify that in the part nnan4 of the wort-W>,which is gertnit Is issued, I shall not employ any person in any manner so as to become subject to the workers'
wmpensatlon laws of e1 m' , apd agree all ould b come subject to the Workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
complywiththese pro smn r� n
ttra'nt Signa re:r t I "Date:'vJv a (J
ING: FAILURE CURE,WORKERS'bau2EusAit N CDV RAGE IS NLAWFUL AND SHALL SUBIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
A
THOUSAND DOL RE (5100.000), IN ADDITION TO THE COST OF PENSATION, 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. Uc. N Class x
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 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:
1 hereby affirm that under penalty of perjury that I EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Protestors
Code: Any city or county which requires a permit to 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 Dlvislon 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 appllcant 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
n 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.).
(rte- as owner of th roperty.-am.EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
__Code: eco ect9rs License Le not apply to an owner of property who builds or Improves thereon, and who contracts for such protect with a contractor(s)
license urs M t the Contracto s Lice a Laws:T
❑ 1 am e - unde rc. Business and Professions Code for this reason:
Ow ve ed by driver's license.ZENo ( Dod�v.Li
erscense No. /.�
Explies:�' alf7 d
Verification of Ownership by (type of locomen '.e. - property tax bill or deed)f.-'a.-.�
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 6, California Administrative Code).
❑ 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 e
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 ❑ 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 theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes Elhlo
v' h Mesa Fire Department may require the preparation, certification and filing with the Fire
(Section nt of of the California Health and Safety Cade provides that the Costa p ir q p p g
Department of an RMPP by businesses which are required to register acutely hazardous materiels with the Fire Department.
4 If en RMPP is presently required, hes Section 25534 of the California Health and Safety Code been fully complied with? LJ Yes ❑ No
5 Does he will the applicant or present or future building occupant require for the work which Is the subject of this a plication ePPermit for such eonstruetlon or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? � Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
..................._................._.........................__..._........................................................_._...........................__..................._.._............................_....................................................................................._................................._....................
6 Will any part of the facilityto be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(Ii yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
..
............................................................................................................................................................................................................................................................................................................................................. ............................................
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
...................................................................................................................._..................................._........................................................................................_....................................._..........................._........................_............................._........
B (II 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:
CE FICAqPLIANCEi0Z, ALfiH- IZAT1ON OF ENTRY: I codify under penalty of perjury that I have read this application and state that the information given is
corract.
ep y'with all 3 to laws ap city ordiryences relating to building construction, and authorize representatives of the City of Costa Mese to enter upon the
or inspectio urp9 94 1 agree not t ccupy or allow occupancy of any building authorized by this permit until final inspection.
And/Or Authorized Applicant Date
CODE It. INSPECTION TYPE gAIE INTMAL5 CODE) INSPECTION TYPE gl,jE I ILLS
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 f , , 222 Final Site
204 Final Demolitions 3l •o? n1Y 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mestrLV8TRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 330 E 15TH ST Status: ISSUED
Suite No Applied: 05/30/2007
Vicinity: Issued: 05/30/2007
Parcel Nunmbec
42531101
Applicant: DAVID KAIMI NIEMANN
Address: 1273 STARLIT DR
Phone: 415-871-9945
LAGUNA BEACH, CA Zip 92651
Owner: STIEFEL, LINDA L
Address 3359 VIA TIVOLI
Phone: 949-350-2867
COSTA MESA, CA, Zip: 92626
Contractor: DAVID KAIMI NIEMANN
Address: 1273 STARLIT DR
Phone: 415-871-9945
LAGUNA BEACH, CA Zip: 92651
License: 828096
SCOPE OF PERMIT
NEW 1,884 S.F. 2 STORY S.F.D.
ISSUED BY:
ELECTRICAL INCLUDES: 1,884 S.F., 6 LIGHT FIXTURES, 3 OUTLETS AND 2 SWITCHES FOR THE
GARAGE. 1 TEMP. POWER POLE. Aer r'60 S, Jim/
FEE SUMMARY
Quantity
ISSUE FEE
523.50
$0.00 0
Temp service test
$0.00
Standing Section
Res. a/c package
$0.00
$0.00 0
New Res (1-2 units)
$105.50
1884
New Res (3+units)
$0.00
0
Pool / Spa
$0.00
0
Lighting Fixts
$6.60
6
Recepl Outlets
$3.30
3
Switches
$2.20
2
Non Res Appl
$0.00
0
Res Appl
$0.00
0
Service to 200a
$0.00
0
Service to 1000a
$0.00
0
Service over 1000a
$0.00 ;
- _ 0
Motors to 1hp
$0.00
0
Motors to IOhp
$0.00
- 0
Motors to 50hp
$0.00
0
Motors to 100hp
$0.00
0
Motors over 100hp
$0.00
0
Communication drops
$0.00
0
Sub panel to 200a
$0.00
0
Pale Light Pkg
$0.00
0 '
Sign Circuits
$0.00
0
Temp Pwr Pole
$23.50
1
Intermed Pole
$0.00
0 -
FEE SUMMARY
Quantity
Temp Dist System / Lighting
$0.00 0
Busway /100 It
SO.00 0
Standing Section
$0.00 0
Misc Electrical Equipment
$0.00 0
Transformers up to -1 kva/kw
$0.00 0
................up to 10 kva/kw
$0.00 0
.................up to 50 kva/kw
$0.00 0
.................up to 100 kva/kw
SO.00 0
..................over 100 kva/kw
$0.00 0
Low Voltage Equipment
$0.00 0
Low Volt Wiring System / Ckt
$0.00 0
- - Misc. Conduit
$0.00 0
Misc. Conductor "
$0.00 0
Circus (gen or ride): _
S0.00 0
Circus (meth ride or lights)
$0.00 0
Christmas Tree Stand
$0.00 0
Fireworks Stand
$0.00 0
Other Electrical Fee
$0.00
Investigation Fee
$0.00
Plan Check Fee
$0.00
Reinspection Fee
$0.00
TOTAL CALCULATED FEES $164.60
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codea, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of permit.
FOR INSPECTIONS CALL: (714) 754-5626
24 646 (6100)
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.
M,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 Insurance carder and policy number are:
�--
'(Th 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 C ifomie an agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply With mese provi ons.
AppBemlY�/Slgnalure-- _-r.,�� o
WARNINGG FNLURE TO SECURERfRS' ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EM PL R TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
II.
THOUSAND DOARE ($100,000), I ADDON 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 license n or prov igns of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Pr essions Code, and my license is in full
(force'and effect. Uc� a �•�_ _ _ less-n—,l"S
niractofs'Si� ` ate:—. - - "S • yv
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 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.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's 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:
❑ 1 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 -lore than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 6, 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 ❑ 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 hazertlous meterials7 ❑Ves ❑ 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 theappplicant 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 It an RMPP Is presently required, hes Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
................................................................ .................................................................... .............................................. _............................. .... ................................................................................................................................................. _............ _.....
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a gpermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building .
8 Will any pan of the facility to be constructed under Ihis permit ba within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(It yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
.........................................................................................................................................................._............................ _.................................................... .................. _.................k_...n............_ry......... f h
7 If a Permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the wort which Is the subject o this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ 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 a tete laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described prop rty for insc Ion purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
g ure Of Legal O)yner(s) 7 DF7@i
r uthorized Applicant--...,_,,_
CODE r. INSPECTION TYPE gaTfi BRIDAL$ CODE I INSPECTIONTYPINTITIALS
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
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
PLUMBING PERMIT
Job Address:
330 E 15TH ST
Status: ISSUED
Suite No
FEE SUMMARY
Applied: 05/30/2007
AMT
Issued: 05/30/2007
Vicinity:
AMT
QTY
AMT
Parcel Nunmber:
42531101
$23.50
Laundry Tub / Washer
Applicant:
DAVID KAIMI NIEMANN
Sump Pump
$0.00
ISSUED BY:
Address:.
1273 STARLIT OR
0
Landscape Irrigation
$0.00
0
Swimming Pool
Phone:
415-871-9945
Backflow Preventer
$0.00
LAGUNA BEACH, CA
Zip:
92651
4
Owner:
STIEFEL, LINDA L
0
Bathtub
$9.80
Address
3359 VIA TIVOLI
$9.80
1
Urinal
$0.00
0
Phone:
949-350-2867
0
Process Piping (per 10 ft)
COSTA MESA, CA
Zip:
92626
$0.00
Contractor: DAVID KAIMI NIEMANN
Address: 1273 STARLIT. DR
Phone: 415-871-9945
LAGUNA BEACH, CA Zip: 92651
License: 828096
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiratlon of this permit.
FOR INSPECTIONS CALL: (714) 7545626
2aa646 (SM)
SCOPE OF PERMIT
NEW 1,884 S.F. 2 STORY S.F.D.
PLUMBING INCLUDES: 1 BATHTUB, 1 GAS (1-4 OUTLETS), 4 P -TRAPS, 1 PRESSURE REGULATOR,
1 SHOWER, 1 KITCHEN SINK, 4 WASH BASIN, 3 WATER CLOSETS, 1 WATER PIPING AND 1 WATER
HEATER. /uF ; s_ 4w
FEE SUMMARY
AMT
QTY
AMT
QTY
AMT
QTY
ISSUE FEE
$23.50
Laundry Tub / Washer
$0.00
0
Sump Pump
$0.00
0
Backflow, irrigation
$0.00
0
Landscape Irrigation
$0.00
0
Swimming Pool
$0.00
0
Backflow Preventer
$0.00
0
P -Trap
$39.20
4
Trap Primer
$0.00
0
Bathtub
$9.80
1
Pressure Regulator
$9.80
1
Urinal
$0.00
0
Clarifier System
$0.00
0
Process Piping (per 10 ft)
$0.00
0
Vacuum Brkr Bkflow(1-4)
$0.00
0
Connect (Ice,Soda,etc)
$0.00
0
Receptors
$0.00
0
Vacuum Brkr Bkflow(5+)
$0.00
0
Dental Units
$0.00
0
Septic Tank
$0.00
0
Wash Basin
$39.20
4
Dishwasher
$0.00
0
Sewer Cap for Demo
$0.00
0
Wash Basin Set
$0,00
0
Drain, Floor
$0.00
0
Sewer Connect
$0.00
0
Waste and Vent System
$0.00
0
Drain, Rainwater
$0.00
0
Sewer Private Line
$0.00
0
Water Closet (Toilet)
$29.40
3
Drain, Roof
$0.00
0,
_ Shower
$9.80
1
Water Heater/vent
$12.30
1
Drinking Fountain
$0.00
0
Sink, bar
$0.00
0
Water Piping (Inst or Rep.)
$9.80
1
Expansion Tank
$0.00
0
Sink, commercial
$0.00
0
Water Re -pipe
$0.00
0
Gas Earthquake Valve
$0.00
0
Sink, Floor
$0.00
0
Water Service
$0.00
0
Gas (1-4 outlets)
$6.15
1
Sink, kitchen
$9.80
1
Water Softener _
$0.00
0
Gas (Over 4 outlets)
$0.00
0
Sink, service/mop
$0.00
0
OTHER
$0.00
Gas Repipe
$0.00
0
Spa (private)
$0.00
0
VIOLATION
$0.00
Gas Service
$0.00
0
Spa (public)
$0.00
0
PLAN CHECK
$0.00
Interceptors (Grease, Oil)
$0.00
0
REINSPECTION
$0.00
0
Interceptors (Sand Auto ) S0.00
0
TOTAL CALCULATED FEES:
$198.75
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiratlon of this permit.
FOR INSPECTIONS CALL: (714) 7545626
2aa646 (SM)
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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.
10-1 have and will maintain workerscompensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
1v1y workers' compensation Insurance comer and policy number are:
banter:--- Pplicy'Number.-^
=(Th' section need not be completed if the permit is valued atone hundred dollars ($100) or less.)
C7 I certify that in the pe o ce the work for which this permit is Issued, I shell not employ any person in any manner so as to become subject to the workers'
compensation laws o III rni eggqppp eze that If I should become subject to the workers' compensation provisions o1 Section 3700 of the Labor Code, I shall forthwith
comply with these pr cions.
plioeMVIP'Signatdte:��
GWARNING' FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPL ER 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 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed u p Visio spf Chapter (commencing with Section 7000) of Division 3 of the Business anAProfessi I Code, and my license Is in full
antl aHact, Lie. d b�.�'
ontractors Signature: �"--^ 1 - 4�%tYey�--- •'g0
(moi
CONSTRUCTION LENDING AGENCY:
❑ 1 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: 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.).
❑ 1, 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 Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 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 -pore than thirty-six (36) teat 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? ❑ 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 Callfomla 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 appplicant or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ElJ0
(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 II an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
_...............__........................................__.................._..........................................................___........................_...or'k......................__..........................................................a..*6_'o'..............._......-........_.............1o' n. _............._...i,......-..
5 Does or will the applicant or present or future builtling occupant require for the work which Is the subject age c this a plication a ertnit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency! � 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 fadlity to be constructed under this permit be within 1000 feat from the outer boundaries of a school? ❑ Yes ❑ No
(It yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
.................... ......................................... .._.......................... .............................. ..... _.._.............................. ................................ _............................... _............................................................ _._.................. __............... _................................ _.........
7 It a permit from the South Coast Air OualiN 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 press bed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ 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: 1 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' s e ion purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
51 nature Of Legal Owner(s)---Date �-7G- off- .
AhtOLr Authorized App -
CODE INSPECTIONTYPE gAM INTITIA4S CODE. INSPECTION TYPE gAffi INTRIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical Qn
1266 Pool Spa Final 208 Final Plumbing -O p
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
RDM
SURVEYING
INC.
RON MIEDEMA L.S. 4653
V23016 LAKE FOREST DRIVE #A 409
LAGUNA HILLS, CA 92653
(949)858-2924
(949)R59-1439 Fax
romsurveymg(gcox.net
May 3, 2007
w- 000-1 i
PAD CERTIFICATION:
TO: City of Costa Mesa, Inspection Dept
RE: 330 — 334 15'' Street, Costa Mesa
To Whom it may concern,
I hereby approve the 3 building pads for this project.
I have checked the top of dirt in conformance with the approved plans.
If you have any questions regarding this matter , please contact me.
Sincerely,
1440
RonMiedema
RON MIEDEMA g,
Date
Na 4653 )v- J
OF
i
Sent By; LI STIEFEL; 714435180; j Uan-IR-06 5:2f
,. �...
f + I f
FAX
To: Burt Morgan Fax# 714-7514 4856
From: Linda Stiefel Ph# 949-350=,2867
j 18 January, 2006
2 pages I
Dear Burt-
Iam sending this fax at the suggestion of Bonnie in the Building Depart
was concerned that you hadn't been advised as to the status of the buil
�grading permit applications for my property at 330 E. 1.5th St.
ReGrading# G-04-00023 1
!Building Account #s B-05-00011, B-015-00012 and 13-05-00013
I
As the applications were expiring, I applied to the Planning Commission
extension of time relative to PA-04-22. At their meeting on October 27,
1 unanimous approval was granted by the adoption of Planning Commissi
j Resolution PC-05-69, due to expire on September 27, 2006.
I I
j I trust this information will help you to update the grading and building
related to the property. I
I If you have any questions or concerns, you may contact Wendy Shih, o
any time.
fThank you for your attention in this matter.
Page 1/2
I'
II
She r
and
or an
.005,
n
91es
me, at
Laurence Randolph Associa
Real Estate Apprelsal Services
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DATE 6-14-79
-RAL CONTRACTOR Owner -Builder DESCRIPTION of WORK Add Z bdMS.
a. 117-262-69 LOT TRACT FIRE ZONE VALUE $14.000. 00
.INSPECTIONS Si notu re
Data
TYPE V
GROUP
1
ZONE
R2
501EPER
SUBCONTRACTOR
MITS ISS
D
GAS
Data Number
Sian ature
WATER
Plumbin
ROUGH PLUMBING
/
aA`
PROP. SWR. LINE [D HOUSE CON.
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUND POWER Q.
ROUGH WIRING�
4ft,
nd
-L
an!' P I_��f i
I 1
TRENCHES FORMS STEEL REINF.
_'f
FLO R SYSTEM
tit
BONG BEAM I j STEEL REINFORCE
SHEATHING
FRAME AND FLASHING
t
LATHING — IN OUT
VI Vi
PL R. BROWN COAT
gjj1
, O
ST A.,_(URAL,FINAL
HEATING. VENT., REFRIG. AND A.C., FINAL
PLUMBING_ FINAL AND GAS TEST
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ELECTRIC, FINAL
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a
.�' COSTA MESA BUILDING -SAFETY DEPARTMENT APPLICATION
P.O. BOX 7200 COSTA MESA, CALIFORNIA 92626
0505 6[14179 102.98
M19TR60WRI. pE_RMIJ 02.98
- P - -
RECEIVED BY ERMIT —
For Applicant to Fill in Completely —Use Ink Only
p
B
-
BUILDINGn I
I r'1 C1BUILDING
A.P. NO. ! ..
ADDRESS D J t /'1r
OWNER OR
ADDRESS 33
�• s..�
G. v^
j� .�
TENANT 1`
.
UNIT
MAILING ,s
ADDRESSQ `-t' "f`
SPACE N NO.
TR.NO./
BLK.
TEL.
CITY a NO.
NEW ADD ALTER REPAIR MOVING DEMOLISH
CONSTRUCTION //77
LENDER e i
BRANCH
OWNER
ADDRESS /
VALUE4W
ARCHITECT �1 �Si.TMf kS TEL.
USE 80$
0.
((�
ADDRESS ttit
ZONE ie?, T
PE ' ROUP
APPROVED
�J
CONTRACTOR
BY
DATE
ADDRESS
/ TEL.
CITY NO.
STATE CITY
APPROVED SETBACKS
LIC. NO. �� LIC. NO.
SIZE r (_ NO. OF BLDGS
(FROM C/ S
OF LOT t p NOW ON LOT
VSE OF
�
EXISTING BLDG. I/LC e.
R SIDE 13 FT.
Separate permits are required for
L. SIDE —7 FT.
electric, plumbing and heating work:
REAR 460 FT.
USE OF BUILDING AND WORK TO BE PERFORMED
PLANNING ACTION
�♦l
('I a Q 2 e
DATE
APPROVED
APPROV
.e/
1 hereby acknowledge that I have read this application and state
that the above information is correct and agree to comply with
all laws regulating building construction, and I shall not employ
any person In violation of the workman's compensation laws of
the State of California.
I hereby certify that I am properly licensed as a contractor under
SQ. FT.
the State of California Business and Professions Code, Division 3,
/T4E MOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, and that such licenses are in full force and effect, or I
THE PURPOSE OF ESTABLISHING
A PERMIT FEE ONLY:
am exempt from the provisions of the State of California Business
and Professions C94. Division 3, Chapter 9.
VALUATION
PERMIT FEE $
PLAN CHECK $
Signal of ' __w
Permittee f
$/ �u U
TAX $
or
l
Authori etl gent Date
/
TOTAL PAID $
OWNERBRELIN ISABEL G. DATE 3-15-6o
JOB ADDRESS 330 E. 1 th St. BUILDING PERMIT
AP. No. il(-ZOl-Ol LOT TRACT FIRE ZONE DESCRIPTION OF WORK .l.nLer, Aller.
INSPECTIONS
DATE I GROUP J TYPE I/ ZONE R -LI
tµ ';;zrground Soil U.G. Water
SUBCONTRACTOR PERMITS ISSUED
DATE NUMBER
ti"r_?rground GaS
Overhead Water and Gas
Rough Heating
Rough Plumbing
Miscellaneous
J
Prop. Swr. Line House Con. St. Swr.
Sprinkling System
Heating, Final
T
Plumbing Fixtures
klb /
Final Gas Test
Construction Pole
Underground Power
9 i
Rough Wiring
/,L/
' .d .at .' _ i ! —/ - c
/.20 7 3 ✓
Trenches Forms Steel
'
Floor System
Steel Reinforce Chimney Re -Rod
Bond Beam
Sheathing
Fri7ne and Flashing-
O
Ik0X--:rg, In out
I:i�er, brown coat
Plumbing Fixtures, Final
Electric Fixtures, Final
Building, Final
OCCUPANCY -
-
IS
Form 410-5M-11-59 S•B P
11581
rn jIS871
COSTA MEGA B"DING-SAFETY DEPARTMENT
P. O. BOX 917 COSTA MESA. CALIFORNIA
For Applicant to Fill In Completely
TYPE OR PRINT
BUILDING
ADDRESS O J
COSTA MESA. CALIFORNIA
HE RECENED
ofi'.Sr 1 L O V L\
FINANCE DEPT.
rITY OF COSTA MESA
APPLICATION FOR PERMIT
BUILDING
For Office Use Only
'11RHCE
NO.
NO6I�
OWNER1 iV.\rQ. l
MAIL 1\
IRHC81P�i
EDATE•EC�s
ISSUED
ADDRESS I IV
�I
3PHDATE
"4?_ deQ IV
BUILDING
o r0 Na sV
DDRE
ITECT TEL.
ENGINEER
MESA. CALIFORNIA
...< NO.COSTA
FIRE
ADDRESS
ZONE TYPE GROUP
APPROVED ��
CONTRACTOR
BY DATE
ZONING
ADDRESS
�O-'
ZGN
NO. OP q
I
UBE OP NM
I
CITY
I
PLANS r
BUILDING
n
STATE TEL.
LEGAL
LIC. NO./ NO.
DESCRIPTION
1_
I J I
(� I
OF LOT (9 ` I b I
NO. OP BLOCS. x
NOW ON LOT
. / / _ a /
A. P. NO. b
f
USE OF
']T
YARDS EVES
EXISTING BLDG ra .t
APPROVED ALLOWED
SETBACK LINE FROM
(CENTER LINE BT.1
CENTER OF 6iReET /'-' REAR YARD
FRONT FT.
IN.
I
I
I
BIDE YARD LEPT
RIGHT E
R. SIDE -' FT.
IN.
DESCRIPTION OF WORK
L. SIDE • FT.
IN.
I II I)(, 11 I
Ne.Y ALTERATION ADDITION
REAR -L'4FT.
IN.
REPAIR II MOVING I II DEMOLISH I
APPROVED DATE
^
BUILDING �� NO. OF /
1
-
SIZE ROOMS STORIES i
EXTERIOR WALL ROOF1
COVERING COVERING SI,IN
USE OF BUILDING_AND WORK TO BE PERFORME
2 V�Go/�
naZ \
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
THE AMOUNT SHOWN UNDER VALUATION IB FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM-
PURPOBH OF ESTABLISHING A PERMIT
FEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
VALUATION
BUILDING CONSTRUCTION,
SIGNATURE OF 9
/)�
PERMIT FEE
$
PERMITTEE
Cl
�
$
PLAN CHECK
$
AUTHORIZED AGENT
TOTAL FEE
S�