HomeMy WebLinkAboutF2009-0183 - PermitsCity of Newport Beach
Building Department FIRE COMBO Permit No: F2009-0183
PO Box 1768 Newport Beach, California 92658-8915
Permit Counter Telephone (949)644-3288
Inspection Requests/Telephone (949)644-3255
Job Address: 1 HOAG DR NB
Inspector Area: FIRE
OF LOT
Owner:
Address:
Phone:
Applicant:
Address:
Phone:
HOAGHOSPITIAL FD&C
500 SUPERIOR AVE
NEWPORT BEACH CA 92663
949-764-4486
BALBONA JOSEPH
10980 WILSHIRE BLVD
LOS ANGELES CA 90024
3104733555
Code Edit : 2007
Type of Construction:
Occupancy Group:
Added /New sq.ft. Bldg:
Added /New sq. ft. Garage:
No of Stories:
No of Units :
Flood Zone:
Bldg Sprinklers:
U
0
0
0
0
Description: R/R (E) FIRE LINES
0738-2009
Legal Description: 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:
KEMP BROS CONSTRUCTION INC
10135 GEARY AVENUE
SANTA FE SPRINGS CA 90670
949-764-6648
149816
08/31 /2010
6T03012109
12/31/2009
Worker's Compensation Insurance
Carrier: OLD REPUBLIC
Policy No: AICW92360901
Expire: 06/01/2009
Issued Date: 06/25/2009
Setback- Front:
Rear:
Left:
Right:
Architect:
Address:
Phone:
Engineer:
Address:
Phone:
Designer:
Address:
Phone:
Special Conditions:
BALBONA JOSEPH
10980 WILSHIRE BLVD
LOS ANGELES CA 90024
310-473-3555 State Lic: C006451-:.
BLACK JOHN
PO BOX 260875
ENCINO CA 91426-0875
213-381-3400 State Lic: C-021510
Construction Valuation: $40,000.00
Building Plan Check Fee :
Fire Permitllnspection Fee:
Fire Plan Check Fee:
TOTAL FEE : $553.35
$0.00
$403.20
$145.15
FEES
Counter Review
Zoning Plan Check Fee
Records Management:
Plan Check Fee : $145.15
$0.00
$0.00
$5.00
Fee Due at Permit Issuance : $408.20
$0.00
$0.00
PROCESSED BY:
ZONING APPROVAL:
FIRE APPROVAL :
•• •
• • •
•• • •
• • • •
• •
OTHER DEPARTMENT:
• ••• • • • • • • •••
•rj ArCHCKB BY:�
• • • • • •
• i1i'PRtOVAL TO ISSUE:
PERMIT EXPIRES 180 DAYS AFTER ISSUANBEr014 LA�T tY4 D INSPECTION
• • • • • • • •
• • •• • • • • •
• • • •
•• ••• • • •• •• •••
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 the 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
Professions 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 not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do (--) all of or ( J portions of the
work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner ofproperty who through employees' or personal effort, builds or improves the PERMIT EXTENDED
property, provided that the 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 it was not built or improved for the
purpose of sale).
ACTION DATE: " BY;
PERMIT EXPIRED
PERMIT CANCELLED
I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, PERMIT FINAL
Business and Professions Code: The Contractors' State License Law does not apply to anowner of property who builds or
improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors State License CERTIFICATE OF
Law).
❑ I am exempt from licensure under the Contractors' State License Law for the following reason:
By my signature below I acknowledge that, except for my personal residehce in which I must have resided for at least one year
pnor to completion of the improvements covered by this permit, I cannot legally sell 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 Professions Code, is available upon request when this application is submitted or at the
following Web site:httpJ/www.leginfo.ca.gov/calaw.html.
Signature of Property Owner or Authorized Agent Date
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code, and my license is injull force and effect.
License Class License No.
q6'0` Contrgnature
WORKERS' COMPENSATION DECLARATI
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, SUBJECT AN EMPLOYER TO
CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDRION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES:
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, issued by the Director of
Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
o.
rig
have and will maintain workers' compensation insurance, as requiredby,Section 3700 of the Labor Code, for the
ance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are:
.farrier Policy Number Expiration Date
- Name of Agent Phone #
* 0 I certify that, in the perfor {. nce of the work for which this permit is issued, I shall not employ anyperson in any manner
so as to become subject o t workers' compensation laws of alifornia, and agree that if f shouldbecomesubject to the
workers' compensation p:a i Cns of ion 3700 of the Labor Code, 1 shall forthwith comply with those provisions.
Signature of App 5,. I`' ice` �— +Fts V ela'D9
DECLARATION REG •ING 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 (Section 3097, Civil Code).
Lender's Name
Lender's Address
• • ••• •
By my signature below, I certify to each of the following: • • • • • •
• .•M•
• • • .•
• • •• • •
I am the property owner or authorized to act on the property owner," tie
•
I have read this application and the information I have provided is orrect... • • • • • •
• .• • •
I agree to comply with all applicable city and county •' . inances and state laws relating to building construction.
I authorize representatives of this city or county to e;� r the above -identified property for inspectio oses.
Signature of Property Owner or Authori - • ent
Print Property Owner's or Aut
01/01/2009
ent's Name:
. .
• • •• •• •• •
•
• • • • •• ••• ••
• • •• • • •
• • _ •
,1I�qoq mpg - a
OCCUPANCY ISSUED
FOR OFFICE USE ONLY