HomeMy WebLinkAboutXR2023-0333 - MiscxV-1Q2;S -0 333
CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachra.gov 1 (949) 644-3200
OWNER -BUILDER ACKNOWLEDGEMENT AND INFORMATION VERIFICATION
(HSC 19825)
NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been s bmitted i7yqur name Iis(ing yourself as the b Ilder of
the property improvements specified at la ( l�U �Q . IJQuJ� . ( �12_6 6e
We are providing you with an Owner -Builder Ackno dgment an Inform tion Verification Form to
make you aware of your responsibilities and possible risk you may incur by having this permit issued in
your name as the Owner -Builder.
We will not issue a building permit until you have read, initiated your understanding of each
provision, signed, and returned this form to us at our official address indicated. An agent of the
owner cannot execute this notice unless you, the property owner, obtain the prior approval of the
permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DCTIONS: Read and initial each statement below to signify you understand or verify this information.
'(11. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an
-Builder" building permit that erroneously implies that the property owner is providing his or her
own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious
financial risk for any injuries sustained by an unlicensed person and his or her employees while working
on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully
acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
fride
y property2. 1 understand building permits are not required to be signed by property owners unless they are
nsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I
rstand that I may protect myself from potential financial risk by hiring a licensed Contractor and
hg the permit fitted in his or her name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list
Tlicense numbers on permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed
ontractors, and the total value of my construction is at least five hundred dollars ($500), including labor
an aterials, I may be considered an "employer" under state and federal law.
6. I understand if I am considered an "employer" under state and federal law, I must register with the
Mate and federal government, withhold payroll taxes, provide workers' compensation disability insurance,
and contribute to unemployment compensation for each "employee." I also understand my failure to abide
bse laws may subject me to serious financial risk.
C7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds
ale -family residential structures cannot legally build them with the intent to offer them for safe, unless
all work is performed by licensed subcontractors and the number of structures does not exceed four
within any calendar year, or all of the work is performed under contract with a licensed general building
Contr ctor.
8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be
liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any
latent construction defects in the workmanship or materials.
Fcr \O ner_buildcr vcrifdoc 08/12/16 1 of
z
9. 1 understand I may obtain more information regarding my obligations as an 'employer" from the
al Revenue Service, the United States Small Business Administration, the California Department of
Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the
California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www,cslb.ca.gov for
iinformation about licensed contractors.
10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and
erstand that I am the party legally and financially responsible for proposed corstruction activity at the
fr.vittvi
g address: vAJ '
I agree that, as the party legally and financially responsible for this proposed construction
I will abide by all applicable laws and requirements that govern Owner -Builders as well as
5empl ers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to
of the information I have provided on this form.
Licensed contractors are regulated by laws designed to protect the public. If you contract with someone
who does not have a license, the Contractors' State License Board may be unable to assist you with any
financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also Important for you to understand that if an unlicensed Contractor
or employee of that Individual or firm is injured while working on your property, you may be held liable for
damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible
for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property
owner and returned to the City of Newport Beach, Building Division, for issuing the permit.
Note: A copy of the property owner's driver's license or form notarization is required to be
presented when the permit is Issued to verify the property owner's signature.
Print name of property owner:
Property Owner's
Date:
Note: The following Authorization Form is required to be completed by the property owner only
when designating an agent of the property owner to apply for a construction permit for the
Owner -Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal
responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file
the documents necessary to obtain an Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address: «j
gzigo
Name of Authorized Agent: _JVA ) Tel No lT(( L4 , -7(7— 331
Address of Authorized Agent: (C((5����14A�s��ef FO A
I declare under penalty of perjury that I am the property owner for the address listed above and I
personally filled out the above information and certify its accuracy. Note: A copy of the owner's driver's
license, form notarization, or other verb ion acceptable to the agency is required to be presented when
the permit is issued to verify the p e s signature.
Property Owner's Signature: Date: z113 z
Note: A copy of the owner's driver se or form notarization is required to be presented when the
permit is issued to verify the property owner's signature.
Furrrs\o"cr builder verif.doc 08/12/16 2 of2
(4 Orange County Sheriff's Department
Technology Division 0
Emergency Responder Radio System Authorization to Operate on Licensed Frequencies
In accordance with FCC Part 90, §90.219, as representative of license holder for the frequencies used
by the Orange County CCCS under FRN ti 0001527001 and assigned to this facility as shown below,
approval to operate a single FM transmitter is granted for the device and location shown below.
Continued approval to operate is conditional, based on continued compliance with NFPA 1221-72, CFS
510, CFR 47, FCC Part 90, §90.219, County and Local ordinances and guidelines. This instrument is valid
for one calendar year from the date of grant.
Site ID:
1243107
FCC Site ID:
SBOO11681
Property:
Atria Senior Living
Manufacturer:
ADRF
On Site
Kevin Lugo
PSR-78-9533-X
Contact:
Model:
Address:
393 S. Hospital Road
Serial Number:
P789533X204270
8o0MH1-6MH2
City:
Newport Beach
Mode:
B
#Filters:
800MH2-31VIHz
Phone:
949 642 5861
Location:
Lower Level ERRCS Equipment Room
Email:
keviu.lueo(datriaseniorlivine.com
Dial Out Line:
(949) 6423617
Local Site Coordinates:
33.626186°
-117.928697'
Donor Site Coordinates:
33.632175'
-117.937822°
UPLINK TRANSMITTIONS
NOT APPROVED
FOR THIS SYSTEM
Frequencies
Assigned and approved:
Countywide
South
WQZ938
WPMZ481
O-HA
Uplink
Dmnlln4
u'lla
tl .-1
(.tu)
(MHz)
gannet
I...)
(MHz)
1
860.9625
815.9625
1
853.9250
808.9250
2
860.7125
815.7125
2
853.9000
808.9000
3
860.4625
815.4625
3
053,6750
808.6760
4
860.2125
815,2125
4
853.6250
808.6250
5
859.9625
814,9625
6
853.3750
808.3750
6
859.7125
814.7125
6
853A250
808.1250
7
859.5625
814.5625
7
852.8750
80].8]50
8
B59.4625
814.4625
g
852.8250
807.8250
91
859.2125 1
814.2125
q
852.5250
00].6250
10
858o625
013.9625
10q851.1250806.12W
807.3750
11
8583125
8137125
11907.1250
12
858.4625
B134625
12806,8750
13
058.2125
513.2125
13W6.625014
857.9525
812.9625
14806.375015
857,7125
B12.7125
15
806.175016
85].4fi25
8124625
16
806.12W
17
85].2125
812.2121
18
856.9825
B119625
]9
856.7125
811.7125
20
856.4625
811.4625
21
8562125
811,2125
22
855.7125
810.7125
Approval Date: 6/12/2023 By:
Must be Posted with Amplifier
Bruce L Cobb OCSD
FCC GROL PG 1114686
OCSD/COMMS
Approval to Operate rev 2022
Third Party Test Report
Review Date 6/12/2023
Engineer B. Cobb
Site ID:
1243107
Project Name:
Atria Senior Living
Site Address:
393 S. Hospital Road
City:
Newport Beach
Site Owner
On -Site Contact:
Kevin Lugo
Address:
393 Hospital Road
City:
Newport Beach 92663
Phone:
949 fi42 5861
Email:
kevnlugo@atriaseniorlivina.com
Fire Jurisdiction:
Newport Beach
Construction Contractor
Company:
DASWAVE
Contractor Contact:
Jeff Gamier
Email:
jgamler@commwave.com
Third Party Testing
Date Conducted:
4/5/2023
Company:
Dishnet Direct
Testing Agent
Said Melia
Email:
said@dishnetilnect.com
Report Filenme:
20230405 Aria Newton Beach ATR.ndt
Pass/Fail
Remarks
Technician Certification
FCC
DAS
P
Summary
Test description
PP
Test requirements per applicable ordinances
P
Test methodology
P
Test Equipment
Models
Serial Numbers
P
Calibration Dates
P
Site Description
Site Number
Location of primary components within property
P
Signal Booster FCC Certification
P
Model and Serial number of all active components
Amplifier or Master Unit
P
Remote Amplifiers
-
Battery Backup Units
P
Remote Alarm Reporting Devices
P
Phone number of line used for auto dialer
P
Site Coordinates
P
Number of Floors
P
BDA
Manufacturer P
Model: P
Srerial Number: P
Operating Mode (A/B): P
Assigned Cells
Primary: P
Secondary: P
Mutual Aid: -
Assigned sites)
Primary: P
Secondary: P
Mutual Aid: -
Date of most recent prior test report
Inspection Result Summary Page
List requirements and Pass/Fail Result
Interior Signal Strength (Downlink)
Exterior Signal Strength (Uplink)
DAQtest
Correct Frequency Filtering
Uplink Muting Enabled
Spurious Uplink Emissions Measurement
Quiescent Noise Floor Measurement
Donor Antenna Azimuth
Backup Power Supply Battery Condition
Backup Power Supply Calculated Runtime
Backup Power Load Test
Physical Condition of Installation
NEMA 4/311 compliance of Equipment Enclosures Inter -cabinet cabling
AC Power Termination
Power Cut -Off device
Grounding and Lightning Protection
Interference Test
Auto Dialer Test
Isolation Tests
Amplifier Gain Measurements
Uplink for both Cells
Downlink for Both Cells
Any other applicable test results
Detailed Test Results
Donor Site Path Profile
Graphic representation of horizontal and vertical paths
Donor Site(s) Name
Azimuth (degrees Magnetic) to Donor Site(s)
Path Length (Miles)
Calculated Path Loss to donor site(s)
Graphic or tabular verification for all required tests (following)
System primary and backup power
One hour load test or pulse -load battery capacity test.
Verify ALL active components operating on backup power
Amplifier/Master (Headers)
Remote amplifiers
Fault display
Auto dialer
System gain and measured RF power
Uplink and downlink
Show gain for one channel Uplink and one channel Downlink
near -far (uplink only)
12/8/2022
N/A
P
P
N/A (Uplink amplification not approved for this system).
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
PP
PP
Stated in "Inspection Results'.
Stated in "Inspection Results".
Stated in "Inspection Results".
p� Downlink only
P Downlink only
Uplink not authorized
Ambient noise floor
Amplifier powered off
Active DAS, if used, powered on
Show span of 15-20MHZ centered at 859MHz (Downlink) and 814MHz (Uplink) P
Measured at BOA Donor antenna feed point (DL Free) P
Measured at BOA Service antenna feed point (UL Fregl P
If an active DAS is used, provide a screenshot of the noise entering the BDA -
from the active DAS
Active noise floor
Amplifier powered on
Active DAS, if used, powered on
Show span of 15-20MHZ centered at 859MHz(Downlink) and 814MHz(Uplink) P
Measured at FDA Donor antenna feed point(UL Freq) P
Measured at BDA Service antenna feed point (DL Freq) P
(fan active DAS is used, provide a screenshot of the noise entering the BDA from the active DAS
Antenna systems isolation
Inject reference signal to donor antenna system at 814MHz P
Show Injected power level P
Show Measured signal from DAS system P
Downlink coverage measurement
All Floors PP
Grid layout compliant P
Uplinkfree space loss calculation
Using measurements from Downlink test provide calculated transmission and noise
B
levels anticipated at the assigned donor site for each supported cell.
Show results for near and tar examples.
Operation
Determine and document DAQ for all grids.
Inspect and document
Physical condition of equipment and installation
Digital Images
1. Headend Equipment
P
2. Headend cabling
P
3. Donor Surge protector
P
4. Donor antenna and supporting structure
P
S. Interior of amplifier cabinet
P
6. Interior of BAD cabinet
P
7. Typical DAS antenna
P
8. Any items requiring repair or support
Uplink not Authorized
Uplink not Authorized