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Home My WebLink AboutF2005-0340 - PermitsCity of Newport Beach Building Department FIRE COMBO Permit No: F2005-0340 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 DR BIdg:1 Floor: Inspector Area:.//-/ '1� Owner: Address: Phone: Applicant: Address: Phone: HOAG HOSPITAL 1 HOAG DR NEWPORT BEACH CA 92663 AIRGAS - WEST INC 4007 PARAMOUNT BOULEVARD LAKEWOOD CA 90714 818-535-1429 Code Edit : 2001 Type of Construction: VN Occupancy Group: 11.2 Added /Newsq ft Bldg: Added /Newsq. ft. Garage: No of Stories: 1 No of Units : Flood Zone: Bldg Sprinklers: Suite: Legal Description: Construction Valuation: $5,200.00 PROCESSED BY: ZONING APPROVAL: FIRE APPROVAL : Fire Plan Check Fee : Fire Permit/Inspection Fee: Records Management: Investigation Fee: Residential Issuance Fee Contractor: Address: Phone: Con State Lic: Lic Expire: Bus Lic: Lic Exp Date: AIRGAS - WEST INC 4007 PARAMOUNT BOULEVARD LAKEWOOD CA 90714 818-535-1429 256141 01/31/2007 BT30002401 01/31/2006 Worker's Compensation Insurance Carrier: INS CO OF THE STATE OF PA Policy No: 2981693 Expire: 12/17/2005 Issued Date: 07/13/2005 FEES $120.00 $120.00 $22.50 $0.00 $0.00 Description of Work: MEDICAL GAS PIPING (SURGERY CENTER) 1819-2005 Architect: Address: Phone: Engineer: Address: Phone: Designer: Address: Phone: Special Conditions: Counter Review : Zoning Plan Check Fee: AL FE)E : 262.50 TOTAL PAYMENT : $0.00 TOTAL DUE : $262.50 OTHER DEPARTMENT: PLAN CHECK BY:: APPROVAL TO ISSUE: PERMIIT EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION INSPECTOR State Lic: State Lic: $0.00 $0.00 $0.00 S0.00 ir 931 APPROVALS DATE BY COMMENTS FIRE PROTECTION UNDERGROUND ROUGH PIPE THRUST BLOCKS EXCAVATION UNDERGROUND PIPING FLUSH UNDERGROUND HYDRO TEST UNDERGROUND/BACKFLOW APRV. SPRINKLER HYDRO TEST SPRINKLER FLOW TEST SPRINKLER ROUGH PIPE STANDPIPE HYDRO TEST STANDPIPE FLOW TEST STANDPIPE ROUGH PIPE CHEM SYSTEM FUNCTION TEST CHEM SYSTEM APPROVAL CO2 SYSTEM APPROVAL FM 200 FUNCTION DRY CHEM SYS FUNCTION TEST DRY CHEN SYS FUNCTION APRV. HALON SYS FUNCTION TEST HALON SYS FUNCTION APPROVAL HOOD SYSTEM APPROVAL DOCK PROTECTION ROUGH DOCK PROTECTION HYDRO DOCK PROTECTION FLOW FIRE ALARM SYSTEM ROUGH WIRING SYSTEM FUNCTION TEST CENTRAL STATION MONITOR FIRE MISC. TANK REMOVAL TANK INSTALLATION/TEST TANK PIPING PRESSURE TEST FUEL MODIFICATION OTHER OWNER -BUILDER DECLARATION 1 HEREBY FOR RMTHE UNDER PENALTY O (SECPERJURY THAT NEAM SAND EXEMPTPFROMTHE CONTRACTORS ACTCRY LAWLIRENSEHICTREFOLLOWINGARMITTN (SEC TOMES,ALTER, IMPROVE, VE,DE OLISH.OR E:PAY CITY OR OODURE WHICH REQUIRESTSSS PERMIT ALSOCONSTRUCT.QHE APPLICANT FOR SUCH PERMIT TO FILE Y A STRUCTURE, EMENT IAS ISSUANCE. ALSO RLICENEST RSUAANT FOR SUCH PROVISIONS OFILEE SIGNEDSTATEMENT THAT IC OR SHE IS LICENSED PURSUANT THE PROVISIONS OF THE CONTRACTORS LICENSE LAW (CHAPTER 9 (COMMENCING WITH SEC 7000)O OF OIV 3 OF THE BUSINESS AND PROFESSIONS N ANY OR THAT OF E SHE 15 BY ANY THEREFROM AND THE BASIS FOR THE ALLEGED EXEMPTION CON ANY PENALTY OFN T THANFIVE HUNDREID LAR A$500) SUBJECTS THE APPLICANT TOACIVIL PENALTY OF NOT MORE THAN FIVE HONORED 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 PROFESSIONSCODE THE CONTRACTORS LICENSE LAW DOES NOT APPLYTO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVESTHEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTSARE NOT INTENDED OR OFFEREOFOR SALE IF,HOWEVER. THE BUILDINGORIMPROVEMENTIS 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 ) I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED j{ 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 IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED I PURSUANT TO THE CONTRACTORS LICENSE LAW.) I AM EXEMPT UNDER SEC. BB P C FOR THIS REASON DATE OWNER LICENSED CONTRACTORS 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 IN FULL FORCE AND EFFECT LICENSEE LASS V 2'3 C.L.• C' c %%3 OJ LIC NO 2..?,S�/ CTOR f.7,free j WORKERS' COMPENS%YION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS 5L I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION. A5 PROVIDED FOR BY SECTION 3700 OF THE LABOR CODE, FOR THE I PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REQUIRED BY THPE 3700 OF THE LABOR CODE, FOR THE PERFORMANCEINSURANCE THE WORK FOR CY THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE CARRIER POLICY NUMBER ( I HIS Jt1I ION NEED NO I Ut V VMHLt I EL) IF INt PFHMI I IS FON (JNt HUNIIHtL) DOLLARS ) (5100) OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE0.1 I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 5O A5 TO BECOME SUBJECT TO THE { WORKERS' COMPENSATIONLAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME ( SUBJECT TO THE WORKERS' COMPENSATION PROVISIONSOF SECTION 37000F THE LABOR CODE. I SHALL FORTHWITH COMPLY ITH THOSE PROV )PNS / S 7c3 ') 5J APPLICANT OV-es-- I ARN NG FAILLTE TO SE SURE WOR R$l6OMPENSATION COVERAGE 15 UNLAWFUL. AND SHALL S..EJLOT..N EM LOYERTC CRIMINAL ENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND COLLARS 451 W,4J0), .N AOLITION TO THE COST OF COMPENSATION. DAMAGES A5 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES CONSTRUCTION LENDING AGENCY P ! I HEREBY AFFIRMUNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR 1 d, FERFORF,ANCE J. . HE WORK?OR l.HICH THIS PERMIT 15 ISSUED (SEC 3097. CIV C ) L'NO'R'S NAME _ LENDER'SADDR`FS FINAL IfrukAh 60 vat rt. IL tie didw'4' sliv I I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 4 F CORRECT I AGREE TO COMPLY WITH ALL CITYAND COUNTY ORDINANCES ANC STATE LAWS RELATING TO BUILDINGCONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVESOF THIS COUNTY TO ENTER I L"'IN T'1r/9OVE V'NTIO"'FO PPOPERTY FOR INSPECTION PURPOSES 7;4/e L ii�i7or-'c 6 ir('l.1' L Es7� ' R IITT'_E NAME (PRINT; Lo r 2 -G Forms\BldF,rePermitBack TURF OF PERMI EE City of Newport Beach Building Department FIRE COMBO Permit No: F2005-0340 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 Bldg:1 Floor: Suite: Description of Work: MEDICAL GAS PIPING (SURGERY CENTER) 1819-2005 Inspector Area: FIRE Legal Description: Owner: HOAG HOSPITAL Contractor: AIRGAS - WEST INC Architect: Address: 1 HOAG DR Address: 4007 PARAMOUNT BOULEVARD Address: NEWPORT BEACH CA 92663 LAKEWOOD CA 90714 Phone: 818-535-1429 Phone: Phone: Applicant: AIRGAS - WEST INC Con State Lic: 256141 Address: 4007 PARAMOUNT BOULEVARD Lic Expire: 01/31/2007 LAKEWOOD CA90714 Bus Lic: BT30002401 Phone: 818-535-1429 Lic Exp Date: 01/31/2006 Code Edit : 2001 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: Worker's Compensation Insurance VN Carrier: INS CO OF THE STATE OF PA 11.2 Policy No: 2981693 Expire: 12/17/2005 1 Issued Date: 07/13/2005 Engineer: Address: Phone: Designer: Address: Phone: Special Conditions: • State Lic: State Lic: 1' Construction Valuation: $5,200.00 Fire Plan Check Fee : Fire Permit/Inspection Fee: Records Management: Investigation Fee: Residential Issuance Fee $120.00 $120.00 $22.50 $0.00 $0.00 FEES Counter Review : Zoning Plan Check Fee: TOTAL FEE : $262.50 TOTAL PAYMENT : $262.50 TOTAL DUE : $0.00 $0.00 $0.00 $0.00 $0.00 PROCESSED BY: ZONING APPROVAL: FIRE APPROVAL : OTHER DEPARTMENT: PLAN CHECK BY:: APPROVAL TO ISSUE: PERMIIT EXPIRE 160 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION APPROVALS DATE i BY COMMENTS FIRE PROTECTION UNDERGROUND ROUGH PIPE THRUST BLOCKS EXCAVATION UNDERGROUND PIPING FLUSH UNDERGROUND HYDRO TEST UNDERGROUND/BACKFLOW APRV. SPRINKLER HYDRO TEST SPRINKLER FLOW TEST SPRINKLER ROUGH PIPE STANDPIPE HYDRO TEST STANDPIPE FLOW TEST STANDPIPE ROUGH PIPE OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LICENSELAW FOR THE FOLLOWINGREASON (SEC. 70315. BUSINESSAND PROFESSIONSCODE ANY CITY OR COUNTY WHICH REQUIRESA 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 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 6 ALLEGED EXEMPTION ANYVIOLATIONOF SEC 70315 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500). I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044. BUSINESS AND PROFESSIONSCODE THE CONTRACTORS LICENSELAW DOES NOT APPLY TO AN OWNER OF PROPERTYWHO BUILDS OR IMPROVESTHEREON, AND WHO DOES SUCH WORK HIMSELF i OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES,PROVIDEDTHAT SUCH IMPROVEMENTSARE NOT INTENDED OR OFFEREDFOR SALE IF.HOWEVER, THE BUILDING OR IMPROVEMENTIS SOLO 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 ) I. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC 7044, BUSINESS AND PROFESSIONSCODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF THE PROPERTY WHO BUILDS OR IMPROVESTHEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW I CHEM SYSTEM FUNCTION TEST CHEM SYSTEM APPROVAL CO2 SYSTEM APPROVAL I AM EXEMPT UNDER SEC , B 8 P C FOR THIS REASON DATE OWNER FM 200 FUNCTION DRY CHEM SYS FUNCTION TEST DRY CHEN SYS FUNCTION APRV. HALON SYS FUNCTION TEST HALON SYS FUNCTION APPROVAL HOOD SYSTEM APPROVAL DOCK PROTECTION ROUGH DOCK PROTECTION HYDRO DOCK PROTECTION FLOW LICENSED CONTRACTORS 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 IN FULL FORCE AND EFFECT LICENSE CLASS UC NO DATE CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' C MPENSATION, AS PROVIDED FOR BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED FIRE ALARM SYSTEM ROUGH WIRING SYSTEM FUNCTION TEST CENTRAL STATION MONITOR FIRE MISC. TANK REMOVAL TANK INSTALLATION/TEST TANK PIPING PRESSURE TEST FUEL MODIFICATION {OTHER FINAL 1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE CARRIER POLICY NUMBER (I HIO ]LC I IUN NEtU Nu Bt CUMYLL I ELL IY IHE HEHMII KJR one XUNUHtU UULLAHO (5100) OR LESS) I CERTIFY THAT IN THE PERFORMANCEOF 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' COMPENSATIONPROVISION50F SECTION 3700 OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS DATE: APPLICANT WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S100.000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES CONSTRUCTION LENDING AGENCY I HEREBY AFFIRMUNDER 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 ). LENDERS NAME LENDERS 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 HEREBYAUTHORIZE REPRESENTATIVESOF THIS COUNTY TO ENTER UPON THE ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES. ERMITTEE NAME (PRINT) Forms\BIdFIrePermllBack t c.