HomeMy WebLinkAboutX2021-1437 - Permitsa[rlr City of Newport Beach - Building Division iiii�iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiq II COMB Permit: X2021-1437
} 100 Civic Center Drive, Newport Beach, CA 92660 X 2 0 2 1 1 4 3 7 Project No : 1257-2021
Permit Counter Phone (949)644-3288
Inspection Requests Phone (949)644-3255 Issued Date : 09/10/2021
Combination Type - BLDG ELEC
Inspection Area : 7
PERMIT EXPIRES
180 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION. PROJECTS MUST SE COMPLETED BY 0911012024 OR PERMIT WILL BE INVALID
Construction
Hours: Monday - Friday 7:00 a.m.
to 6:30 p.m. and Saturday from 8:00
a.m. to 6:00 p.m. No work on Sundays or Holidays
Job Address: 20162 BIRCH ST Ile
St: 1 FI: 100
Description: COMM GENERAT
R" PEGASUS SURGERY CENTER"
Legal Desc.: TR 706 LOT 136
LY1/2
Owner: CFM HOLDINGS L
C
Contractor:
HYDAM CONSTRUCTION INC
Architect: ESA MOHAMMED
Address: 20162 BIRCH ST S
E 180
Address:
311 HAIGH RD #201
Address: 311 HAIGH RD STE 201
NEWPORT BEACF
CA 92660
NEWBURY PARK CA 91320
, . THOUSAND OAKS, CA 91320
Phone:
Phone:
805-498-7786
Phone: 805-490-7786 State Lic:CO2'4004 0
Applicant: ESA MOHAMMED
Con State Lic: 951115
Engineer:
Address: 311 HAIGH RD #2C
1
Lic Expire:
08/31/2022
Address:
THOUSAND OAKS
CA 90320
Bus Lic:
BT30075315
State Lic:
Phone: 805-498-7786
Lic Exp Date:
05/31/2022
Phone:
Code Edit : 2019
Worker's Compensation Insurance
Designer:
6�
Type of Construction:
Carrier:
STATE FUND
Address:
,
Occupancy Group: U
Policy No:
9290477
C
Added (New sq.ft. Bldg:
Expire:
0110612022
Phone:
Added /New sq. ft. Garage:
No of Stories: 0
Building Setbacks
Rear: /
Special Conditions:
-
No of Units : 0
-
Front: /
,
Bldg Height: 0
Left: /
Bldg Sprinklers:
Flood Zone: X
Use Zone:
Right: /
Parking Spaces: 0
Fire Hazard Zone : N
_
Construction Valuation:
6 000.00
Building Permit Fee: $522.
)0
Excise Tax:
$0.00 Planning Department
- Fire Department
$0.00
Plan Check Fee: $454.14
Additional Fee:
$0.00 Plan check Fee :
$52.00 Fire Inspection:
$97.00
Overtime Plan Ck: $0.00
Grading Bonds Fee:
$0.00 Fair Share :
$0.00 Fire Plan Rev
Investigation Fee: $0.
0
Grading PC Consultant :
$0.00 SJH Trans :
$0.00 Demolition Fee
$0.00 Building Dept Adm
$0.00
Record Management : $12.
0
0
Grading Permit Fee:
Grading PC Fee:
$0.00 - In -lieu, Housing Fee :
$0.00 Public Works Department - General Service
$0.00
Energy Compliance: $0.
CA Seismic Safety: $0.
0
WQ Insp. Fee:
$0.00 Park Dedication :
$0.00 Refund Deposit
$0.00
Disabled Access : $0.
0
PAN Plan Check:
$0.00 Grading Bond:
$0.00
Hazardous Mat $0.
0
Electrical W
$68.33 San Dist:
$0.00
$0.00
Building Green Fee : $2.
0
Mechanical %:
$0.00 NMUSD Fee:
$0.00
$0.00
Plumbing %:
$0.00
TOTAL FEE
: $1,207.47
Plan Check Fee : $616.94
Fee Due at Permit Issuance :
$590.53
PROCESSED BY:
ZONING APPROVAL:
PUBLIC WORKS APPROVAL:
PLAN CHECK BY:
GRADING APPROVAL: APPROVAL TO ISSUE:
mV-
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicable item(s)
Section 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
ie permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
'rofessions Code) or that he or she is exempt from licensure 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
of more than five hundred dollars ($500).
7 I, as owner of the property, or my employees with wages as their sole compensation, will do U all of or U portions of the work, and the structure is not intended or offered for sale (Section 7044,
Iusiness and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the
nprovements 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 it was not built or
nproved for the purpose of sale).
I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not
pply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State License Law).
7 I am exempt from licensure under the Contractors' State License Law for the fallowing reason:
Iy my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legally
all a structure that I have built as an owner -builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and
'rofessions Code, is available upon request when this application is submitted or at the following Web site:http://www.leginfo.ca.gov/calaw.html.
ignature of Property Owner or Authorized Agent Date
.ICENSED CONTRACTOR'S DECLARATION
hereby affirm urd:Tcr penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of D 3f the Business and Professions ode a i nse is in full force
nd effect. Lirense,Class License No Date eContractor Signature /
IORKERSCQPIOENSATION DECLARATION T
ARMING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE
OST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, ANDATTORNEYS FEES.
hereby affirm rndcrnpenalty of perjury one of the following declarations:
J' I' have and. will maintain a certificate of consent to self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for IN
❑n` ante �f the work for which this permit is issued. Policy No.
I lave and wi!'. 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' compensatior
rauce carrier and policy number are:
arrief Policy Number Expiration Date
ame;of Agent Phone #
J1 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
Iat, if I should become Vbject to the workers�o_mpensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
of
Date sj Zo'p/ 2
CLARATION REGARDING CONSTRU NDING AGENCY
:reby affirm under penalty of perju ere is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code).
ider's Name Lender's Address
my signature below, I certify to each of the following:
I am the property owner or authorized to act on the property owner's behalf.
I have read this application and the information I have provided is correct.
I agree to comply with all applicable city and county ordinances and state laws relating to building construction.
I authorize representatives of this city or county to nter th ove-identified property for inspection purposes. //�� �r1
nature of Property Owner or Authorized Agent / Print Property Owner's or Authorized Aoent's Name /,*r eel kt U
ACTION
PERMIT EXPIRED
PERMITCANCELLED
PERMIT EXTENDED
CERTIFICATE OF
OCCUPANCYISSUED
DATE I BY I DECLARATION
51 OF TITLE 40 AND AQMD RULE
1403
LJ I SUBMITTED ASBESTOS NOTIFICATION TO
LJA5BEST05 NOTIFICATION IS NOTAPPLICABLE TO
PROPOSED DEMOLITION
I FOR OFFICE USE ONLY