HomeMy WebLinkAbout334 15TH ST - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa8U3LDING PERMIT - 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address:
334 E 15TH ST
Suite:
$1,441.75
Vicinity:
$17.95
Primary Occ:
R-3 Dwellings/ Cong Res <10
Parcel Number:
42531101
Applicant:
SMITH, BRAD'
Address:
$2,396.84
Owner: SAMUELIAN, STEPHEN E
Address 20371 IRVINE AV
SUITE 210
SANTA ANA HEIGHTS, CA
Contractor: DAVID KAIMI NIEMANN
Address: 1273 STARLIT DR
LAGUNA BEACH, CA
Zip: 92651
Type of Construction: V -N
Zoning:
Phone: 949 631-3682
Zip:
Phone:
Zip: 92651
Phone: 415-871-9945
License: 828096
Status: ISSUED
Applied: 01/05/2D05
Issued: 05/30/2007
ISSUED BY: -AV
Arch : BRADFORD C SMITH, ARCHITECT Eng:
Address: 365 OLD NEWPORT SL Address:
STE B Phone: 949-361-3682 Phone:
NEWPORT BEACH, CA
Zip: 92662 License: C14146 License:
SCOPE OF PERMIT
CONSTRUCT NEW 1818 SF 2 -STORY SFD (847 SF FIRST FLOOR AREA AND 971 SF SECOND FLOOR) WITH A 454 SF 2 -CAR ATTACHED
GARAGE AND A LAUNDRY AREA WITHIN THE GARAGE, THERE WILL BE A SUPERIOR FIREPLACE (MODEL RD -36; WH REPORT J9902 -5865C-
23) IN THE GREAT ROOM. A
30 SF BALCONY WILL BE CONSTRUCTED OFF THE MASTER BEDROOM.
3 BEDROOMS, 2-1/2 BATHROOMS
REF: G04-00023 AND PA -04.22
Plan Check:
$937.14
Permit:
$1,441.75
SMIP Res:
$17.95
SMTP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total:
$2,396.84
SETBACKS
MAIN STRUCTURE Front 0-0
ACCESSORY Front 0-0
PARKING Existing: 0
FEE SUMMARY
Calc Valuation: $179,529.00
Claim Valuation: $0.00
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 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 appllo bl>s, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the exttlirstion of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
244646(6/00)
DECLARATIONS I
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.
^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 carrier and policy number are:
•Carfei: (�olioyNumbe =`
-(�T,Jhis'section'need not be completed i/ the permit is velu d at one hundred dollars ($100) or less.)
D! 1 certify that in the performance of the work for whi t 's permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of 'tornla, and agree that If I o Id become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith
comply with these pro o s. e . r1 �!
LplicantSigneture:---- [21 �ta: -- -y- 1 J J " O�
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under orv}'�ion Chapter 9 (commencing with Section 7000) of Division 3 of the Bu_sine%and Prof s5ions Code, and my license is in full
force. and. effect.. Lk.-#—�' �Tu Q �#--.17' ` I'7
�Cpntrecbrs Signature:--- NCA^r+'N`� Rate:.-�7-'tiO.OZ"
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code),
Lenders Name: Lender's Address:
Signature: Date:
OWNER -BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). '
❑ 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 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 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).
....................................................................................................................................................................................................................I--......................................................................... .......... ........................ ............ .....................................
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
rDepartment.
an..R.................................................................................................................................................................................................
..................................................................................................equ.iretl,
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 apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
................................................................................................................................................................................l'e"e,................................................................................................. ..........................................................................................
6 WIII any pan of the facility to be constructetl under this permit be within 10001eet 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 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 correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZAT10N 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 in lection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
ature Of Le al Owners)
S ate
AndlOr Authorized Applicant - --� rDate"""--�..`
CODE.. INSPECTION TYPE INTMALS CODE1 INSPECTION TYPE DAM lNTMALfl
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 V a'�
204 Final Demolition 250 Final Building/Occupancy
NEWPORT -MESA UNIFIED SCHOOL DISTRICT
CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES
PURSUANT TO AS 1600 AND AS 181
To: (Xl City of Costa Mesa
City of Newport Beach
( ) County of Orange
Applicant:
Address:
Telephone Number:
iMi Nt2000
Tract/Parcel and Lot Number(s):
Location of Project:
Number of Square Feet of:
Residential Space
Commercial and
Industrial Space
CommerciaVlndustrial Project is: (Check One)
Warehouse
_ RBD
Movie Theater
Mini -storage
Heavy Industrial
Regional Shops
Light Industrial
This project is exempt because
��x $1.84
x $ .30
Motel
_ Bank
Neighborhood Shops
RacquettHealth
_ Hotel
_ Medical Office
Office Park
05-30-21307/7� :3_ F:;
001-071�'305� - n
N° 6633
District Receipt No.
Plan Check NZCb-CM t:-2
Total r
Total
Preschool
Auto Repair
Hospital
_ Large Office
Office Bldg.
Restaurant
Fast Food
This certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections
53080 and 65995. The Building Pemits for this square footage in this proposed development may n94be issued by your jurisdiction.
Checks are to be made payable to Newport -Mesa Unified School District.
By:
AWwrked
The above representation as to square footage is true. Appficant agrees that if it is tater determined that such representations are not
true, then this certificate shall automatically terminate and the appropriate C' ounty shall be notified.
Date: � -� D OT'
APDlicard
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
MECHANICAL PERMIT
Job Address: 334 E 15TH ST
Suite No
Vicinity:
Parcel Number: 42531101
Applicant:
DAVID KAIMI NIEMANN "
FEE SUMMARY
Address:-
1273 STARLIT DR -
--
_
Phone:
415-871-9945-
LAGUNA BEACH, CA
Zip:
92651
Owner:
,STIEFEL. LINDA L.
ISSUE FEE
$23.50
Address:-"
" 3359 VIA TIVOLI -
---
-
-
-
Phone:
949-350-2867 '
-
COSTA MESA,.CA "'" ;, '"
Zip:
92626
contractor:
DAVID KAIMI"NIEMANN
- $0.00
0
Status: ISSUED
Applied: 05/30/2007
Issued: 05/30/2007
ISSUED BY:
- Address:-- 1273 11 STARLIT DR
Phone 415-871-9945 r
LAGUNA BEACH, CA Zip: ..92651
- License 828096" .'
' SCOPE OF PERMIT
REVISED 06-07-07 ADD RADIANT FLOOR HEATING.
NEW 1,571 S.F. 2 STORY S.F.D. -
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.'
REF'. B05-00013
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626
2"646 (WOO)
G
FEE SUMMARY
-Quantity :_ . -_
_. _.. .. .. _. - ..
Quantity
ISSUE FEE
$23.50
- -- Repair;/All Absorbtion Unit
$0.00
0
Inst FAU <100 k BTU
$14.80
1
Repair / Alt Refrigeration Unit
$0.00
0
Inst FAU >100 k BTU
$0.00
0
Ventillation System
- $0.00
0
Repair/ Alt Cooling/Heat .
$13.70
1
Evaporative Cooler
- $0.00
0
Inst / Rep. Recess Wall Htr ,
$0.00
0
Commercial Incinerator
$0.00
0
Refrig Sys <100 k BTU
$0.00
0
a- 'rpomestic Incinerator -
$0.00
0.
Refrig Sys >100 k BTU
=- $0.00
0
'} ` - - Compressors / Absorption Systems
-
Gas Piping -
- $6.15
1 Up to Thp./;100 k BTU
$0 00 f
=0
Factory Fireplace
$10.65
1
' -; 3 To,15 hp /•500 ;k BTU�,
-. $0.00
.0
Hood w/Meeh Exhaust '
- $10.65-< 1'''::
-' ' "15 To 30'hp % 1',000lk=B-TU'.�=/ %
$0.00
` 0
VAV Box
'40.00,
0 -
- 30 To 50 ho/ 1,750 k BTU',// /
$0.00'
0
Vent Fan / Single Duct
$36.25.'
-5
- Over 50 hp / Over 1,750 BTU'
,$0,00
0
Appliance -
- $0.00 -�
0
Boilers -
Fire Dampers
" $0.00
0 . -.
- "Up to 3 hp
0
Smoke Dampers
--, $0.00,--
0___
- - -__- 3.To 15 -hp'-" ti �" -
$27.15
1
Inst or Relocate All Vent
$0,00,
' 6
- - 15 to 30 hp
,-"
$0.00
0
Air Handlers < 10000cfm
$0:00.`,
_
0 -
_
- 30 to 50 hp'
$0.00
0
Air Handlers > 10000cfm
$0.00
-0
Over 50 hp
$0.00
0 '
Floor Furnace
$0.00
0
1 Other Mechanical Fee
Floor or Suspend Heater
$0.00-0
- ,',1 ; Investigation Fee.
$0.00
Plan Check Fee:/ ,.
$0.00
- Reinspection Fee"
$0.00
TOTAL CALCULATED FEES
$152.65
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626
2"646 (WOO)
G
DECLARATIOMS
WORKERS' COMPENSATION DECLARATION: • - .,, 1
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.
_
_❑_ 1 have and will maintain work rs' mp n� sation 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 I nce a der and olicy nu or are:
-Carder: Policy Number:
_(This section need not be complef e p rmu Is ua an
v e hundred dollars ($100) or less.)
(is
y/ 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, an t I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions. ---t
�It-^^-^ O
Applicant Signature: Date:� r
C-=-
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 37M 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 Professio Code, and license is in full
�� ` ` �
-force end effect. LIC. # V Class # _ C S
rContractors Signature:
rDate:
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 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 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:
❑ 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). ..... [...1..No..........................................
............................................................................................................................................................
a r registration form for acutely hazardous materials?............Yes.....................................................................
to fil���.............
2 Does or will the applicant or present or future building occupant need to e a eg y ❑ ❑
(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 or suchconstruction or modification
LJ U
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).
.........................n........................................................................................................................................................e-e-.........................................-n-d-ati.........................................................................................................................................
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)...............................n .....
................... ..............................................'
....................................................................................................................................................................................................................................
M1
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the workwhich is a 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 all state laws and ity ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purpos . I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Sign re Of Le I Owners) - ate
[-�—ArktiOrAut ' dApplicant - ( Data -
CMDF N. INSPECTION TYPE PATE IgTITALS CODE INSPECTION TYPE FAZE
1616 Fixed System Final Fire Prevention 206 Final Mechanical 3;� -c�OUT9
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Root 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
(714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
,lob Address: 334 E 15TH ST
Suite No
Vicinity:
Parcel Number: 42531101
MECHANICAL PERMIT
ISSUED BY:
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
Status: ISSUED
SCOPE OF PERMIT
NEW 1,571 S.F. 2 STORY S.F.D.
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.
/tt('; /XIS• odd/3
FEE SUMMARY
Quantity
Quantity
ISSUE FEE
$23.50
Repair / Alt Absorbtion Unit
$0.00
0
Inst FAU <100 k BTU
$14.80
1
Repair / Alt Refrigeration Unit
$0.00
0
Inst FAU >100 k BTU
$0.00
0
Ventillation System
$0.00
0
Repair/ Alt Cooling/Heat
$13.70
1
Evaporative Cooler
$0.00
0
Inst/ Rep. Recess Wall Htr
$0.00
0
Commercial Incinerator
$0.00
0
Refrig Sys <100 k BTU
$0.00
0
Domestic Incinerator
$0.00
0
Refrig Sys >100 k BTU
$0.00
0
Compressors / Absorption Systems
Gas Piping
$6.15
1
Up to 3 hp/ 100k BTU
$0.00
0
Factory Fireplace
$10.65
1
3 To 15 hp / 500 k BTU
$0.00
0
Hood w/Meth Exhaust
$10.65
1
15 To 30 hp / 1,000 k BTU
$0.00
0
VAV Box
$0.00
0
30 To 50 hp / 1,750 k BTU
$0.00
0
Vent Fan / Single Duct
$36.25
5
Over. 50 hip / Over 1,750 BTU
$0.00
0
Appliance
$0.00
0
Boilers
Fire Dampers
$000
0 -
Up to 3 hp -
$0.00
0
Smoke Dampers
$0.00
0
3 To 15 hp
$27.15
1
Inst or Relocate Appl Vent
$0.00
0
15 to 30 hp
$0.00
0
Air Handlers < 10000cfm
$0.00
0
30 to 50 hp
$0.00
0
Air Handlers > 10000cfm
$0.00
0
Over 50 hp
$0.00
0
Floor Furnace
$0.00
0
Other Mechanical Fee -
Floor or Suspend Heater
$0.00
0
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 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
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the ei
FOR INSPECTIONS CALL: (714) 754-5626
2446-06 (6/001
IDECLARATIOMS
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.
4�h a
LM❑- 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:
aC1 • .akcyNumber:_
(Thi section need not be completed if 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'
compensationlaws of Iifomia, agTge that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provi to -
T-TLAy"PX 1%`-' S ' ' (:)r
Appre te:—
Signatu: �e
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed d rfjrovision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full
�
,force an�. Uc..#. y Class #
'CZ5tractodsSignature,----- N''�-�� ('pate:---- 0 •O
l
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 ($500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work
himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). '
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor($)
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 Tore 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 Cade 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 o1 500 pounds, or a volume o1 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)............I.............................
.....................................................................................................................................................................................................................................................................................................................
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 ❑ 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 aEEermit 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).
.............................................I.....................
....................................................................................................................................................................................................................................................................................................................
6 Will any pan 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 Cade).
................. ..............................................................d.............................n...n........n.............................ni....
..............................................................................................................................................................
7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is require for the workwhich is the subject o this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Ves ❑ 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:
CERTIFlCATE 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 inspcut n purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
igin u Legal Owner(s)Date
S • 3t� - �'
V_,,Knc1J0rAuthoi Applicant
CODER. INSPECTION TYPE AE INTITIALS CODER INSPECTION TYPE QSIF. INITIALS
1616 Fixed System Final Fire Pr ntion 206 Final Mechanic I
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Root 210 Final Electrical
201 Final Block/Retaining Well 212 Fin Fire Pr v ntion
202 Final Factory Fire Place 22 Ina tanning pproval
203 Final Sign 2
204 - Final Demolition 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa ff-9bTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 334 E 15TH ST
Suite No
Vicinity:
Parcel Nunmber 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
ISSUED BY:
Status: ISSUED
Applied: 05/30/2007
Issued: 05/30/2007
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, a all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this pl .
FOR INSPECTIONS CALL: (714) 754.5626
244646 (6/00)
NEW 1,818 S.F. 2'STORY S.F.D.
ELECTRICAL INCLUDES: 1,818 S.F.,
GARAGE. 12a' ,JOS- 45517
SCOPE OF PERMIT
6 LIGHT FIXTURES, 3 OUTLETS AND 2 SWITCHES FOR THE
FEE SUMMARY
Quantity
Quantity
ISSUE FEE
$23.50
Temp Dist System / Lighting
$0.00
0
Temp service test
$0.00
Busway /100 ft
$0.00
0
Res. a/c package
$0.00
Standing Section
$0.00
0
New Res (1-2 units)
$101.81
1818
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
$6.60
6
................. up to 50 kva/kw
$0.00
0
Recept Outlets
$3.30
3
................. up to 100 kva/kw
$0.00
0
Switches
$2.20
2
..................over 100 kva/kw
$0.00
0
Non Res Appl
$0.00
0.
Low Voltage Equipment
$0.00
0 -
Res Appl
$0.00
0
Low Volt Wiring System / Ckt
$0.00 -
0
Service to 200a
$0.00
0
Misc. Conduit
$0.00
0
Service to 1000a
$0.00
0
Misc. Conductor .
$0.00
0
Service over 1000a
$0.00
, -. 0
Circus ( gen or ride) _
$0.00
0
Motors to 1 hp
$0.00
0
Circus (mech ride or lights)
$0.00
0
Motors to 10hp
$0.00
0
Christmas Tree Stand
$0.00
0
Motors to 50hp
$0.00
- 0
Fireworks Stand
$0.00
0
Motors to 100hp
$0.00
0
Other Electrical Fee
$0.00
"
Motors over 100hp
$0.00
0
"
Communication drops
$0.00
0
Investigation Fee
$0.00
Sub panel to 200a
. $0.00
0
Plan Check Fee
$0.00
Pole Light Pkg
$0.00
0
Reinspection Fee
$0.00
Sign Circuits
$0.00
0
Temp Pwr Pole
$0.00
0
TOTAL CALCULATED FEES
$137.41
Intermed Pole
$0.00
0
_
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, a all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this pl .
FOR INSPECTIONS CALL: (714) 754.5626
244646 (6/00)
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.
fi ha a 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:
Policy�Number:— -�
section need not be completed if Me permit is valued at one hundred dollars ($100) or less.)
FGaic�Qemer:—"-'
I certify that in the performance 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 lifo ie � a d 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 provi io -
U oil
�AppO/ ggeture:,
1`7
WARNING: FAILURE TO SECUREO_ RS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I,am,licensed der ov of hapter 9 (commencing with-Section 7000) of Division 3 of the Business anr{TfessiC C�o, and my license is in full
a� ct:-Llc-p•'- H .,,- Class #, Ij
(force
Cont Icer or.'aSigneture:-"'-'=�'= Date:— S i1 - O
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 1116 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
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.).
❑ 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, 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 Tore 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). ������� .......No ��...............�1 .......................
........................................................................I...............1....1....1.....1..... ...............
.builds ...ant need to file a registration form for acutely materials?
2 Does or will the applicant or present or future building occupant g y ❑ ❑
(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..................................1111.
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 complied with? ❑ Yes ❑ No
..............................................................................................................................................................................................................................................................................................................................................................
S Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a gpormit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
...........................................................................................
........................................................................................................................................................................................................................................................................................
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? . ❑Ves ❑ No
(If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
......o
................11ut....................... .......ire
..............................................................ou-t..................................alit...........................
or w'h'l.
7 If a permit tram the South Coast Quality Management District or other air pollution control district agency is required for the work which is the subject of this
rAires n
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Vas ❑ No
.............................................................................................................................................................11ut.........................................................................................................................................................................................................................
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 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 insp ction purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
SI at re Of Legal Gwner(s) Date
Ani cAuthodzecl Applicant_---!: Y, -Ym-4- r—Date,,
C CODE. INSPECTION TYPE PATE IBTIT9L$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical 2`
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
(714) 754-5273 • Fax (714) 754-4656 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
PLUMBING PERMIT
.lob Address:
334 E 15TH ST
ISSUE FEE
523.50
Status:
ISSUED
Suite No
$0.00
Bathtub
$9.80
Applied:
05/30/2007
Connect (Ice,Soda,etc)
$0.00
Dental Units
$0.00
Issued:
05/30/2007
Vicinity:
$0.00
Drain, Rainwater
$0.00
Drain, Roof
$0.00
Parcel Nunmber:
42531101
Expansion Tank
$0.00
Gas Earthquake Valve
SO.00
Applicant:
DAVID KAIMI NIEMANN
Gas (Over 4 outlets)
$0.00
ISSUED BY:
$0.00
Address:
1273 STARLIT DR
Interceptors (Grease, Oil)
$0.00
Interceptors (Sand Auto )
$0.00
$0.00
0
Phone:
415-871-9945
0
Septic Tank
$0.00
LAGUNA BEACH, CA
Zip:
92651
4
Sewer Cap for Demo
Owner:
STIEFEL, LINDA L
Wash Basin Set
$0.00
0
Sewer Connect
Address
3359 VIA TIVOLI
Waste and Vent System
$0.00
0
Sewer Private Line
$0.00
0
Phone:
949-350-2867
3
Shower
$9.80
COSTA MESA, CA
Zip:
92626
1
Sink, bar
Contractor:
DAVID KAIMI NIEMANN
Water Piping (Inst or Rep.)
$9.80
1
Sink, commercial
Address:
1273 STARLIT DR
Water Re -pipe
$0.00
0
Sink, Floor
$0.00
0
Phone:
415-871-9945
0
Sink, kitchen
$9.80
LAGUNA BEACH, CA
Zip:
92651
0
Sink, servicelmop
50.00
0
License:
828096
Spa (private)
SCOPE OF PERMIT
NEW 1,818 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. 1-tF• r 005. 0=3
QTY
FEE SUMMARY
AMT
ISSUE FEE
523.50
Backflow irrigation
$0.00
Backflow Preventer
$0.00
Bathtub
$9.80
Clarifier System
$0.00
Connect (Ice,Soda,etc)
$0.00
Dental Units
$0.00
Dishwasher
$0.00
Drain, Floor
$0.00
Drain, Rainwater
$0.00
Drain, Roof
$0.00
Drinking Fountain
$0.00
Expansion Tank
$0.00
Gas Earthquake Valve
SO.00
Gas (1-4 outlets)
$6.15
Gas (Over 4 outlets)
$0.00
Gas Repipe
$0.00
Gas Service
$0.00
Interceptors (Grease, Oil)
$0.00
Interceptors (Sand Auto )
$0.00
QTY
FEE SUMMARY
AMT
QTY
AMT
QTY
Laundry Tub /Washer
$0.00
0
Sump Pump
$0.00
0
Landscape Irrigation
50.00
0
Swimming Pool
$0.00
0
P -Trap
$39.20
4
Trap Primer
$0.00
0
Pressure Regulator
$9.80
1
Urinal
$0.00
0
Process Piping (per 10 ft)
$0.00
0
Vacuum Brkr Bkflow(1-4)
SO=
0
Receptors
$0.00
0
Vacuum Brkr Bkflow(5+)
$0.00
0
Septic Tank
$0.00
0
Wash Basin
$39.20
4
Sewer Cap for Demo
SO.00
0
Wash Basin Set
$0.00
0
Sewer Connect
$0.00
0
Waste and Vent System
$0.00
0
Sewer Private Line
$0.00
0
Water Closet (Toilet)
$29.40
3
Shower
$9.80
1
Water Heater/vent
$12.30
1
Sink, bar
$0.00
0
Water Piping (Inst or Rep.)
$9.80
1
Sink, commercial
$0.00
0
Water Re -pipe
$0.00
0
Sink, Floor
$0.00
0
Water Service
$0.00
0
Sink, kitchen
$9.80
1
Water Softener
$0.00
0
Sink, servicelmop
50.00
0
OTHER
$0.00
Spa (private)
$0.00
0
VIOLATION
$0.00
Spa (public)
$0.00
0
PLAN CHECK
SO.00
REINSPECTION
$0.00
0
COMMENTS / SPECIAL CONDITIONS
TOTAL CALCULATED FEES: $198.75
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 pr` 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
x�e(aroo)
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 which this permit Is Issued.
O-l.have and will maintain workers' compensaflon 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:
ylCerriar.---- [Pylicy.NumbeD.
s 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 o1 Ca /' mia, 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 th /vis ns Q
ApPAcant.Signature:— ( i �O
WARMNG-FAILURE TO CURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE 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 affirin that I am licensed un r r wslQ��nsyf Chapter 9 (commencing with Section 7000) of Division.3,oLthe.Business and Professions�ode,9nd my license is in full
force' end`effect. Uc. s'- - U`t b _ r- �CIes3W- IS C� 17
_ContractorsSignature:'--- —
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. 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, 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 cor iracior(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 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 amore 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).
......._ ..................... .............. ..._.................................. ___......................................____._......................._._...................._..__............................___............................................... _......._.__...... _................................. I ...............
.�_...
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, cortification and filing with the Fire
bapartment 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 application appernit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? jJ 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 W III any pen of the faciiiry 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 cartificate 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: Data:
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 constructlon, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property forinspection urposes. I agree not to occupy or allow Occupancy of any building authorized by this permit until final inspection.
nature Le lOwner(s) Date _ Oq—
uthonzed ApplicantDate—,—
CODE I
ale—CODE.. INSPECTION TYPE PlIE INTMALSS CODE INSPECTION TYPE UN RiTMALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical L!
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Roof 210 Final Electrical
201 Final BlocWRetalning 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 BuildinglOccupancy