HomeMy WebLinkAboutX2007-3021 - PermitsCity of Newport Beach
Building Department
PO Box 1768 Newport Beach, Califomia 92658-8915 Permit Counter Telephone (949)644-3288
Combination Type - CIP/ ELEC/ MECH/ PLUM/
COMB Permit No: X2007-3021
Inspection RequestslTelephone (949)644-3255
Job Address: 1 HOAG DR NB
Inspector Area: 7
OF LOT
Owner:
Address:
Phone:
Applicant:
Address:
Phone:
HOAG HOSPITAL FD&C
SUPERIOR AVE STE 300
NEWPORT BEACH CA 92663
949-765-4486
RANEY AARON
17291 IRVINEBLVD #418
TUSTIN CA 92780
949-294-8124
Code Edit : 2001
Type of Construction: VN SPR
Occupancy Group: B
Added /New sq.ft. Bldg: 0
Added /New sq. ft. Garage: 0
No of Stories: 1
No of Units : 0
Bldg Height: 0
Bldg Sprinklers: Y
Flood Zone:
Issued Date: 05/09/2008
Construction Valuation: $700 000.00
Building Permit Fee: $4,075.00
Plan Check Fee: $2,934.00
Overtime Plan Ck: $0.00
Investigatin Fee: $0.00
Record Management: $127.50
Energy Compliance: $338.00
CA Seismic Safety : $0.00
Disabled Access : $582.00
Fee Increase: Fee: $0.00
Additional Fee : $0.00
Hazardous Mat : $25.00
TOTAL FEE : $14,1f5.11.6.
• •
PROCESSED BY:
ZONING APPROVAL:
GRADING APPROVAL:
Project :
Legal Desc.:
Description: TV "ADVANCED TECHNOLOY" 7248 SF BLDG#47
2554-2007 CHG OCC FROM E3 TO B 2554-2007
IRVINE SUB BLK 2 LOTS 169 & 170 POR OF LOTS & BLK 1 172 POR
Contractor:
Address:
Phone:
ADVANCED MEDICAL BUILDER INC
571 N POPLAR STREET UNIT E
ORANGE CA 92868
714-614-1573
Con State Lic: 824317
Lic Expire: 08/31/2008
Bus Lic:
Lic Exp Date:
Worker's Compensation Insurance
Carrier.
Policy No:
Expire:
Building Setbacks
Use Zone:
Parking Spaces
San Dist :
Exdse Tax:
NMUSD Fee:
Grading Permit Fee:
Grading PC Fee:
WO Insp. Fee :
Electrical %:
Mechanical %:
Plumbing %:
• •.
• •
• . . • .
• • •
• •
•.
•
• • • •
•
STATE FUND
238-0003116
05/01/2009
Rear: /
Front: 1
Left: /
Right: 1
0
FEES
iigsPECFCn
Architect: LICAUCO MARGIE
Address: 2973 HADDONFIELD LOOP
FULLERTON CA 92831
Phone: 714-9044004 State Lic:C002814
Engineer: WELTON JEREMY
Address: 23441 S POINTE DR
LAGUNA HILLS CA 92653
Phone: 949-916-3440 State Lic:S-004614
Designer:
Address:
Phone:
Special Conditions:
$0.00 Planning Department -
$0.00 Plan check Fee : $153.75
$0.00 Fair Share : $0.00
SJH Trans : $0.00
$0.00
$0.00
$0.00
$713.13
$611.25
$509.38
Public Works Department -
Park Dedication : $0.00
P/W Plan Check : $0.00
Plan Check Fee : $4,474.36
PUBLIC WORKS APP
PLAN CHECK BY:
• OOOOO • •
• • • • •• APPROVAL TO ISSUE:
• • • • PERMTiTS EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VALID INSPECT!
• • • •• •• .. • •••• ••
OVAL:
•
•
Fire Department
Fire Inspection: 52,852.50
Fire Plan Rev $1,173.60
Demolition Fee
Building Dept Adm $0.00
General Service $0.00
Refund Deposit $0.00
$0.00
$0.00
Fee Due at Permit Issuance : $9,620.75
- sigts
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS UCENSE LAW FOR THE FOLLOWING REASON
(SEC 7031.5, BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE.
PERMIT EXPIRED
DATE:
BY:
DEMOLISH, OR REPAIR ANY STRUCTURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED
STATQMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LICENSE LAW (CHAPTER 9 (COMMENCING
WITH SEC. 7000) OF DIV. 3 OF THE BUSINESS AND PROFESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE
ALLEGEDVIOLATION 5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF
�NO MORE THAN FIVE HUND DOLLARS 0500)0
PERMIT CANCELLED
I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL D0 THE WORK AND THE STRUC-
TURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7074, 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-BUILOER WILL HAVE THE BURDEN OF PROVING
PERMIT EXTENSION
.
L
BUSINESS
THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE.):
AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS 70 CONSTRUCT THE PROJECT (SEC. 7044,
AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF THE PROPERTY WHO BUILDS OR
PERMIT FINAL
I.-3-0g
IMPROVES
THEREON AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRACTORS
SolAtt
soLICENSE
I AM
LAW.).
EXEMPT UNDER SEC B. S P.C. FOR THIS REASON
CERTIFICATE OF OCCUPANCY
I2,-3-0K
ge,(ror,tW
DATE OWNER
TENANT NAME
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM UCENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SEC. 7000) OF
TYPE OF BUSINESS
DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS. IN FULL FORCE AND EFFECT.
L NSE CLASS Jr LICENSE NO. 7 7
/r
TE S/9/ O TRACTOa
FOR OFFICE USE ONLY
WORKERS'
.
I HAVE
LI
I HAVE
ANCE
CARRIER
COMPENS ION DECLARA ION
1 HERESY AFFIRM UNDER PE TY OF PERJURY ONE OF THE FOLL WG DECLARATIONS:
AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF4NSURE FOR WORKERS' COMPENSATION, AS PROVIDED FOR BY SEC 3700
OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SEC 3700 OF THE LABOR CODE, FOR THE PERFORM-
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, MY WORKERS' COMPENSATION INSURANCE CARRIER AND POUGY NUMBER ARE:
POLICY NUMBER
❑ (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS MOO) OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE HALL NOT EMPLOY ANY PERSON IN ANY MAN-
NER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATI WS OF CALIF B11NMID AGREE THAT IF I SHOULD BECOME SUBJECT
TO T,. WORK S' C MPENSATION PROV IONS OF SEC. 3700 OF E LABOR CQO CCCC FORTHWITH COMPLY WITH THOSE PROVISIONS.
0 ICANT:
I/`�/,/\D/A-TE/
WARNING: FAILURE TO SECUR RKERS' COMPEN CO V NLAWFU , AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP O ONE HUNDRED TH D DO 100 00), IN DITION TO THE COST OF COMPENSATION, DAMAGES
AS PROVIDED FOR IN SEC. OF THE LABOR CODE. EREST, AND OR S FE S.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE I5 A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK
FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV.C).
LENDERS NAME
•• • • •
LENDER'S ADDRESS
• •
• • • • • • • • • • •
• • • • •• • •
• •
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL
CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF
LTHIS CRY TO ENTER UPON THE ONED PROPER INSPECTION PURPOSES.
NAME (PRINT) ONED
••
•
••• • • • • • • •
....
• •.. •
///•
S /�((�A•
(SIQMA7URE OF PERMIT7EE DATE / ,
•-
•
•• • •
• • • • •
/
-- •
CITY OF NEWPORT BEACH
BUILDING DEPARTMENT
3300 Newport Blvd.
P.O.Box 1768, Newport Beach, Ca 92658-8915
(949) 644-3275 • Website: www.newport-beach.ca.us/building
CERTIFICATION FORM FOR TITLE 24
BUILDING REQUIREMENTS FOR SURGICAL CLINICS
AND
FREESTANDING OUTPATIENT SERVICES OF A HOSPITAL
This certifies that the following clinic meets the current applicable California Code of
Regulations, Title 24, (including OSHPD 3) requirements.
Facility: Advanced Technology Pavilion
Street Address: One Hoag Drive, Building 47
City: Newport Beach, CA 92663
Type of Facility: Outpatient Imaging Center
Building Permit No.: X2007-3021
Name: Faisal Jurdi
Title:
Deputy Building Official
Street Address: 3300 Newport Blvd.
City: Newport Beach, CA 92658
Signatur
Date:
City of Newport Beach
Building Department COMB Permit No: X2008-1985
PO Box 1768 Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288
Combination Type - BLDG/ / / /
Inspection Requests/Telephone (949)644-3255
Job Address: 1 HOAG DR NB
Inspector Area: 7
OF LOT
Owner.
Address:
Phone:
Applicant:
Address:
Phone:
HOAGHOSPITAL FD&C
500 SUPERIOR AVE #300
NEWPORT BEACH CA 92663
PARRIS MICHAEL C
Project :
Legal Desc.:
ADVANCED MEDICAL BUILDER INC
571 N POPLAR STREET UNIT E
ORANGE CA 92868
714-614-1573
Code Edit : 2007
Type of Construction:
Occupancy Group:
Added /New sq.fL Bldg: 0
Added /New sq. ft. Garage: 0
No of Stories: 0
No of Units : 0
Bldg Height: 0
Bldg Sprinklers:
Flood Zane:
Issued Date: 09/17/2008
Construction Valuation: $20,000.00
Building Permit Fee: $322.20
Plan Check Fee: $231.98
Overtime Plan Ck: $0.00
Investigatin Fee:
Record Management :
Energy Compliance:
CA Seismic Safety :
Disabled ArnPss :
Fee Increase: Fee:
Additional Fee :
Hazardous Mat :
$0.00
$6.50
Soso
$0.00
Moo
$0.00
$0.00
$0.00
TOTAL FEE : $604r686• •
PROCESSED BY:
ZONING APPROVAL: ,
GRADING APPROVAL:
•
Description: EXTEND (E) BLOCK WALL 4'6" X 30 LF
2554-2007
IRVINE SUB BLK 2 LOTS 169 & 170 POR OF LOTS & BLK 1 172 POR
Contractor:
Address:
Phone:
Con State Lic:
Lic Expire:
Bus Lic:
Lic Exp Date:
ADVANCED MEDICAL BUILDER INC
571 N POPLAR STREET UNIT E
ORANGE CA 92868
714-614-1573
824317
08/31 /2010
BT30023363
05/31/2009
Worker's Compensation Insurance
Carrier: STATE FUND
Policy No:
Expire:
Building Setbacks
Use Zone:
Parking Spaces:
San Dist :
Excise Tax:
NMUSD Fee:
Grading Permit Fee:
Grading PC Fee:
WQ Insp. Fee :
Electrical %:
Mechanical %:
Plumbing %:
••• • • •
• • • • • •
• • • • • •
• • • •
••
• ••
238-0003116
05/01/2009
Rear: /
Front: /
Left: /
Right: /
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
0
FEES
Architect:
Address:
Phone:
Engineer:
Address:
Phone:
Designer:
Address:
Phone:
LICAUCO MARGIE
2973 HADDONFIELD LOOP
FULLERTON CA 92831
714-904-4004 State Lic:C002814
WELTON JEREMY
23441 S POINTE DR
LAGUNA HILLS CA 92653
949-916-3440 State Lic:S-004614
Special Conditions:
Planning Department -
Plan check Fee : $45.00
Fair Share :
SJH Trans :
$0.00
$0.00
Public Works Department -
Park Dedication : $0.00
P/W Plan Check : $0.00
Plan Check Fee :
Fire Department
Fire Inspection:
Fire Plan Rev
Demolition Fee
Building Dept Adm
General Service
Refund Deposit
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00 Fee Due at Permit Issuance :
PUBLIC WORKS APPROVAL:
• • •• • PLAN CHECK BY:
• • •• • • • •
• • • • • • •
• • • • •• • • APPROVAL TO ISSUE:
• • • • • • • • • • • • • • PERMITS EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION.
$605.68
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LICENSE LAW FOR THE FOLLOWING RFASON
(SEC. 7031.5, BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, ..
PERMIT EXPIRED
DATE:
BY:
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 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LICENSE LAW (CHAPTER 9 (COMMENCING
WITH SEC. 7000) OF DIV. 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 SEC, 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF
NOR MORE THAN FIVE HUNDRED DOLLARS ($500):
PERMIT CANCELLED
I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUC-
TURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS UCENSE LAW DOES
NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER,
THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLETION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING
PERMIT EXTENSION
THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE.):
•
I, AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044,
BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF THE PROPERTY WHO BUILDS OR
PERMIT FINAL
IMPROVES THEREON AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRACTORS
It-I'O$Ferk-
❑ LICENSE LAW.).
I AM EXEMPT UNDER SEC 8. & P.C. FOR THIS REASON
CERTIFICATE OF OCCUPANCY
DATE OWNER
TENANT NAME
LICENSED CONTRACTORS DECLARATION
DIVISION 3 OFY IRM T THENDER BUSINESS PENALTY
PROFESSIONS CODE, ANDQQD MY LICENSE{,ED UNDER IS IN FULLISIONS OF FORCE AND EFFECTR . (COMMENCING WITH SEC. 7000) OF
TYPE OF BUSINESS
LICENSE S j/ f/'( 3‘ 7
oA
CONTRACTLICENSE
CONTRACTOR%C AY149
- FOR OFFICE USE ONLY
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I H AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED FOR BY SEC 3700
0 THE TABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
I E AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SEC 3700 OF THE LABOR CODE, FOR THE PERFORM-
E OF THE WORX 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 FOR 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 MAN-
NER 50 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 SEC. 3700 OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS,
DATE' APPLICANT:
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 DOLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES
AS PROVIDED FOR IN SEC. 3706 OF THE LABOR CODE. INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK
FOR WHICH THIS PERMIT 15 ISSUED (SEC. 3097, CIV.C).
LENDER'S NAME
• • • •
• • • •
LENDER'S ADDRESS
• • • • •
• •• • • • • ••
• • •
••
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL
CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF
THIS CITY TO ENTER U ABOVE-MENTI ED PROPERTY INSPECTION PURPOSES,
PERMITTEE NAME (PRINT) \
• •
•
•
•
• • '•
• ••
L
• • •'•
• •
• • •
•• • •• • •
NATURE OF PERMITTE
7•SIG•
DA
•
••
•
••• • • ••
•• • •
//
City of Newport Beach
Building Department FIRE COMBO Permit No: F2008-0348
PO Box 1768 Newport Beach, Califomia 92658-8915 Permit Counter Telephone (949)644-3288 Inspection Requests/Telephone (949)644-3255
Job Address: 1 HOAG DR NB 41
Inspector Area: FIRE
OF LOT
Owner: HOAG HOSPITAL FD&C
Address: 500 SUPERIOR AVE STE 300
NEWPORT BEACH CA 92663
Phone: 949-764-4486
Applicant: ADVANCED MEDICAL BUILDER INC
Address: 571 N POPLAR STREET UNIT E
ORANGE CA 92868
Phone: 714-614-1573
Code Edit : 2007
Type of Construction:
Occupancy Group:
Added Mew sq.ft. Bldg:
Added /New sq. ft. Garage:
No of Stories:
No of Units :
Flood Zone:
Bldg Sprinklers:
VN,SPR
B
0
0
1
0
Y
Description: FIRE/MEDICAL GAS (X2007.3021)
2554-2007
Legal Description: IRVINE SUB BLK 2 LOTS 169 & 170 POR OF LOTS & BLK 1 172 POR
Contractor:
Address:
Phone:
ADVANCED MEDICAL BUILDER INC
571 N POPLAR STREET UNIT E
ORANGE CA 92868
714-614-1573
Con State Lic: 824317
Lic Expire: 08/31/2010
Bus Lic: BT30023363
Lic Exp Date: 05/31/2009
Worker's Compensation Insurance
Carrier: STATE FUND
Polley No: 238-0003116
Expire: 05101/2009
Issued Date: 09/04/2008
Setback- Front:
Rear:
Left:
Right:
Architect:
Address:
Phone:
Engineer:
Address:
Phone:
Designer:
Address:
Phone:
Special Conditions:
MissFc
Tqt
State Lic:
WELTON JEREMY
23441 S POINTE DR
LAGUNA HILLS CA 92653
949416-3440 State Lic: S-004614
Construction Valuation: $20,000.00
Building Overtime Plan Check :
Plan check Exten Fee:
Building Fire Plan Check Fee:
TOTAL FEE : $554.68
$0.00
$0.00
$0.00
FEES
Fire Plan Check Fee :
Fire Permit/Inspection Fee:
Records Management:
Investigation Fee:
Residential Issuance Fee
Plan Check Fee : $0.00
$231.98
$322.20
$0.50
$0.00
$0.00
Counter Review :
Zoning Plan Check Fee:
Fee Due at Permit Issuance : $554.68
$0.00
$0.00
$0.00
$0.00
PROCESSED BY:
ZONING APPROVAL:
FIRE APPROVAL :
• ••
• • •
• • ••
m
`:-Ar C-)
• • • •
• • • •
•
•
• • ••
•
OTHER DEPARTMENT:
PLAN CHECKED BY::
APPROVAL TO ISSUE:
• • • • • • • • PjRMIIT EXPIRES 180 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION
•
• • • • • • •
• • • • •• • •
• • • • •
•• •• • • ••• ••
linty
-
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LICENSE LAW FOR THE FOLLOWING REASON
(SEG 7031.5, BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH A PERMIT TO CONSTRUCT. ALTER, IMOVE,
DEMOLISH, OR REPAIR ANY SRUUCTURE, PRIOR TO ITS ISSUANCE. ALSO REQUIRESOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIG ED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF RE CONTRACTORS LICENSE LAW (CHAPTER 9 (COMMENCING
WITH SEC. 7000) OF DIV. 3 OF THE BUSINESS AND PROFESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE
PERMIT EXPIRED
DATE:
BY:
PERMIT CANCELLED
ALLEGED EXEMPTION. ANY VIOLATION OF SEC. 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF
NOR MORE THAN FIVE HUNDRED DOLLARS ($500)'.
II I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL OD THE WORK, AND THE STRUC
TORE 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 THE PURPOSE OF SALE.):
1. I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC.
7044, BUSINESS AND PROFESSIONS CODE: THE CONSTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF THE PROPERTY WHO
BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CON
TRACTORS LICENSE LAW).
• I AM EXEMPT UNDER SEC ' " t,4C P.C. FOR THIS REASON
PERMIT EXTENSION
FIRE PROTECTION
PERMIT FINAL
I'1 IZi I�Q
�bt Q
�`U
FOR OFFICE USE ONLY
• • • • •• •
• • • • • • • • • •
••• • • ••• • • ••
•• • •• • •• • • • • • •
• • • • • • • • • • •
•• • • • •
• • • • • • • •=
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SEC. 7000) OF
DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCT AND EFFECT.
LICENSE LICENSE NO
DATr ' L 1 ( jf CONTRACTOR ( —
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
111 I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONENT TO SELF -INSURE FOR WORKERS' COMPENSATION. AS PROVIDED FOR BY SEC 3700
tA.HE LAB•' CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
r E AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SEC 3700 OF THE LABOR CODE. FOR THE PERFORM -
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 FOR ONE HUNDRED DOLLARS ($100) OR LESS).
NI 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' COMPENSATION PROVISIONS OF SEC. 3700 OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE
PROVISIONS.
DATE- APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CVIL FINES UP TO ONE HUNDRED THOUSAND DOLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES
AS PROVIDED FOR IN SEC. 3706 OF THE LABOR CODE, INTEREST, AND ATroRNErs FEES.
CONSTRUCTION LENDING AGENCY •
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK
FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CMC).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLCATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY
AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS
COUNTY TO ENTER UPON jHEBOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME (PRINT) —1---/
/�
SIGNATURE OF PERMITTEE a i DATE \/ ��� OQ•
1/23/07 rev