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CITY OF NEWPORT BEACH COMMUNITY DEVELOPMENT DEPARTMENT BUILIIINO DIVISION 100 Civic Center Drive 1 P.O. Box 1768 1 Newport Beach, CA 92658-8915 Nv,^w.newportbeachca.00v 1 (949) 644-3200 NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been sul mitt d ' your erne listing yourself as the builder of the property improvements specified at I� `� `I 4 \ S We are providing you with an Owner -Builder Acknowledgment and Information 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, initialed 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 DIRECTIONS: Read and initial each statement below to signify you understand or verify this information. I understand a frequent practice of unlicensed persons is to have the property owner obtain an 'wrier -Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, 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 on my property. 0 2. 1 understand building permits are not required to be signed by property owners unless they are to u de3. 1 u that I may protect myself from potential financial risk by party this responsibility. r ;� 3 sibunderstandnasuantonOwnerrBuiltler1 am the licensed or arty of record On the permit. I hiring and rig a licensed Contractor and having the permit filed in his or her name instead of my own. W�-�,4: I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. CN 5. I understand if I employ or otherwise engage any persons, other than California licensed Co rectors, and the total value of my construction is at least file hundred dollars ($600), including labor 1nd materials, I may be considered an "employer' under state and federal law. Q 6. I understand if I am considered an "employer" under state and federal law, I must register with the state 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 7b these laws may subject me to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, 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 Theli ctor. . 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be able for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. Forms\owner_ builder_verif.doc 08/12/16 1 of 2 4ern 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the ai 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 Lioense Board (CSLB) at 1-500-321-CSLB (2752) or www.cslb.ca,gov for more information about licensed contractors. 910. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: 11. 1 agree that, as the party legally and financially responsible for this proposed construction aotivity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as empl ers. 2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to arty/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 loas 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. r� Print name of property owner: Property Owner's Signature: Date: Z ao 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: i a, LA `1L1 { K sis Name of Authorized Agent: MICA-,t1CA_ J 3cJC" Tel No 2I `LV ?, q&53^ Address of Authorized Agent: (Sol L.�tt) Qv�. ',OioI A!",4f+-1 '64'. 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 verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: 0340A —Date: i Note: A copy of the 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. Forms\owner_ builder_verif.doc 08/12/16 2 of 2-- City of Newport Beach Special Inspector Manual CITY OF NEWPORT BEACH COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658 www.newiportbeachca.gov 1 (949) 644-3200 SPECIAL INSPECTION Final Project Report Project Permit Inspect Inspect W/4" .� MANY, r, �rr,�a��..� r�r�rar.�r•�r, �i�.�la►���r �'�i�«ice eased upon my personal observation and written reports performed, to the best of my knowledge, in accordance workmanship provisions of the Uniformed Building Code. y a� of this work, it is my judgment that the inspected work was -/ with the approved pans, spe�cattons, and the appticabte � /d� Print Full NI NewpwtSeacb Registration No.: Speciallnapectio alProjec[aepart ea/25/2uis i G/ 1,92 G` //,,��68,., 41 /NIT /<./�s, /.�f r� / [� d /Jc J/,�af Adhesive Aa-rchoorri 6rusT+c-dU0ru Checklist fort' Concrete & EWasevmlrrsf Special Inspection shall be In compliance with Section 1701 of the UBC and Section 1704 of the IBC as described below. (See Structur I Draw4'YJ or nspection requirements) CODES 6elemlc Zone/ Project Name: ❑UBC 7997 Sala Ic Design C tegory Project Locatio /" — ❑IBC 2000 G/�'i l��j , Weather... ��_1 Air Temperature: rF / >C) ❑ Iec zooa rDiward Name/Manufacturer, ___. I. Report IVo.:_ expiration Date: ✓0k oR laSpecified Dispenser 0 Specified Mixer Owl Initial Adhesive: (# trigger pulls) Tempaturre,:,�� ("F:_ {� Cu/ re Timeracturers inslailetion instructions) r ll-Thread ❑ Internally Threaded ❑ Torque -Controlled fd'Reber ❑ Other _ 0 Standard d Stainless Steel fl High Strength e/Coating:. _—_(in/mm) ter: ❑ 3/8" � 112" ❑ 5/8" 0 3/4" ❑ 7/8" ❑ 1" ❑ 1 1/4v ❑ #3 ❑ #4 ❑ #5 ❑ a ❑ #7 ❑ #8 ❑ #9 ❑ #10 ❑ #11 ❑ Other Btea Material Type: ❑ NW Concrete ❑ LIN Concrete ❑ Brick ❑ CMU ❑ Other - B;,e Material Strength: ❑ 2000psi ❑ 3000ps1 ❑ 4000ps1 I& Other „ B:.:.y Material Thickness:_ ._ _ fin/mm) B.c<- Material Temperature: (-F / "Cl Drill Bit Diameter:_ _(in/mmi Hole Deptiv__ (In/mm) (core nit diameter. If approved) Drill Bit Type: ❑ Carbide -Tip Drill Bit ❑ Diamond Core Bit ❑ Other (ANSI a212.154994) 6f apprtpnafe an+l nllnw"�ff — _. Hole Condition: O Dry ❑ Water Saturated 13INater Filled ❑ Under Water Hole Cleaning: W Compressed Air ❑ Hand Pump A WireBrush ❑ Nylon Brush ❑:No _ Hole cleaning in accordance with manufacturers' printed installation instructions: ❑ Yes Anchor Application: (please chock an that apply) Qr Tenslon YShear ❑ Overhead O Other_ Anchor insertion: IT, sling motion Annular gap filled wi h,a slue L7 Air Void Free Injection Anchor Spacing:_ -(In/men) Edge Distance:_ /C�y@ ! L._(in/mm) Embedment (her):_ _(in/mm) Installation Torque (if required):_ _(ft-Ib/Nm) Completed by: ,(� _(signature) Date:_ _fprint) Company:_ / ///� //•v ���! V&StM 99.2W7 Fig. 1,11): Exampip of fvDiraf arih®ci,va anrh,, incrPrtfn, chpekfipt f, ,nn,nt nnw n r, a: r ,u:r Stephen Booth INSPECTION SERVICES 847 S. Avocado, Anaheim • 949.689.2744 sbrun ings Cgmail.com /(1 ai Job Address r � City Job Name / Per)N�o/ � �/' ` Issued By Type of Stnmlure Amhhect v Material Description (ty , grade, so ) Engineer C .- se Contra or40, s Inspector(s) Name Subcontractor N Type of Work ete/Rebar Masonry Wood Ins metl Soil Epoxy Prestressed Concrete Other TEST PERFORMED Type Of Sample Slump Quantity in Set AdGaional Remarks on Samples Inspection Summary - Locations of Work inspected, test samples taken, work rejected, job problems, progress, remarks,includes information about - amounts of material placed or work performed, numb5rPtyPe & in m. No est samples taken: St t. Conna ' weld de H.T torqued) checked, etc. 001 .j a 6/ Date y w. ury n wr i nave uussr VUU ins Deal or my Knowledge all of the above reported work unless otherwise noted. I have found this work to comply with the approved plans, specifications, and applicable sections of the governing building laws U/ &//01 Continue on Next Page Page of Time In I Time Out I Reg Hours I O.T. Hours I Cylinders I All inspections based on a minimum of 4 hours and over 4 hours - 8 hours minimum. Over 8 hours charged overtime rate per hour. Saturdays charged at overtime rate. Sundays charged at doubletime rate. IT A/4 fly l ly/4�k/,; f S•/Zf /, Agency Approved by fig J®AI@M u®se®g AuV J9110e1190 411M ueld u0172@WJd I®Ar,l Stephen Booth INSPECTION SERVICES 847 S. Avocado, Anaheim • 949.689.2744 sbrunningsb@gmail.com Job Address 0" t , Job Name t%nn" d (•,� Issued By/ Type of Stmclure Archdecf /cq/ • i Material Description (type, grade, source) 6 Engineer ' L °— Contractor/ 1.. lI� • l /A /"� Inspectors) Name �/ /4 0� Subcontractor Type of Work In ed Concone/Rebar Masonry Wood Soil Prestressed Concrete Other TEST PERFORMED Type Of Sample Slump Quantity in Set Addhional Remarks on Samples Inspection Summary - Locations of work Inspected, test samples taken, work rejected, job problems, progress, remarks, etc. includes information about - amounts of material placed or work performed, number, type & indent. No's of test samples taken: Struct. Connections (Weld made H.T bolts torqued) checked, etc. G AW 1AV , e / / I , ITAI 1�Iolf / Ile 7 r 14 / s / , I , i4j, 'e'r" RH zr� / / r.G • ,p 1l —v/ A yrr Date 7 /y 2 I hereby certify that I have observed the best of my knowledge all of the above reported work unless otherwise noted. I have Continue on Next Page Page of found this work to comply with the approved plans, specifications, and applicable sections of the governing Time In Time Out Reg Hours O.T. Hours Cylinders building laws All inspections based on a minimum of 4 hours and over hours - S hours minimum. Over 8 hours charged overtime rate per hour. Signature of Registered In ctor Saturdays charged at ov rti a rate. Sundays charged a doubletimE rate. Specialivw/r� No. fl 6 Ein Appro Olt, ved b �lE 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.newportbeachea.gov 1(949) 644-3200 Structural Observation Report REPOR't 11 0 , Project Address: Report Date: CNB Inspector Name: 124 24TH ST., NEWPORT BEACH 03-23=2022 Building Owner Name: Owner's Mailing Address (if different from site); Ovmer's Telephone #: Full Name of Structural Observer (SO): SO E-mall Address: SO Telephone #: EDUARDO J. CARRILLO EDDIEC©ECAENGINEERING.COM (562)-708-3586 PLEASE INDICATE STRUCTURAL ELEMENTS AND CONNECTIONS OBSERVED (check FOUNDATIONS SHEAR WALLS �._ FRAMES OIAPHRAOM$ INDICATE LOCATION(( (Floor/Roof) OBSERVED LJ Conventional ❑ Concrete 17 Steel I..) Concrete _ Footings & Slab I Mat Foundation, ❑ Masonry fl Concrete I" I Steel Dock Prestressed Concrete I I (. n.�sons, Piles, ❑ Wood or Manuf I I Masmuy I I Wood Grade Beams Shear Panels___ Other: ❑ Other: I I Other; I I Other: 5i.41Pi —r SSY✓ jvT r,f)W FOOTING Row 6ALc, V"( 21� 117.1 mit`_ � Che�— qc #: Lice C7jel e. 73R9#: I I ITEMS CHECKED ABOVE ARE APPROVED AND WITHOUT DEIFICIENCICtit. CJ OBSERVED DEFICIENCIES AND COMMENTS: ❑ REPORT CONTINUED ON A El FINAL STRUCTURAL OBSERVATION REPORT: �ACHEb h The structure generaliv complies with the approved construction documents, and all observed deficiencies wem I declare that the following statements are true to the best of my knowledge: 1. 1 am the licensed design professional retained by the owner to be in responsible charge of the structural observation; ' -' 2. I, or another licensed design professional whom I have designated above and is under my responsible charge, have performed the required site visits at each significant '6. construction stage to verify that the structure is in general conformance with the " approved construction documents; 3. 1 understand that all deficiencies which I have documented must be contacted, prior to final acceptan the structural systems by the City of Newport beach, Building Division. 03-23-2022 STAMP OF STRUCTURgI SIGN RE OF STRUCTURAL OBSERVER OF RECORD oArEn= OBSERVER ' STRUCTURAL OBSERVATION DOES NOT WAIVE ANY REQUIREMENTS FOR BUILDING INSPECTION BY AUTHORIZED EMPLOYEES OF THE CITY OR NFwPDRT BEgC h, City of Newport Beach Special Inspector Manual r �— CITY OF NEWPORT BEACH COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658 www.newoortbeachca.aov1(949)644-3200 SPECIAL INSPECTION Final Project Report Project Permit Inspecti Inspecti Thkstu ae<W that f pafdbmed tpecia I e ' mthe folbrvingporbomafthe work at the .. above addrnswhich regummd contimous .. atidwftichtrasito. G / r o I i i IA / G✓'/D GiG L O 1 40 WAI Based upon my personal observation and written reports of this work, it is my judgment that the inspected work was performed, to the best of my knowledge, in accordance with the approved pans, specifications, and the applicable workmanship provisions of the Uniformed Building Code. SpedalktspectorSknahm �tLeghtratkm D14ait Cvll.Nam No.: i 68 City of Newport Beach Special Inspector Manual CITY OF NEWPORT BEACH COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658 www.newoortbeachca.00v 1 (949) 644-3200 / �[ SPECIAL INSPECTION REPORT A Project Address: ,2 7 Permit Number: Inspection Type (s): Inspection Date (s): ( ) Periodic ( ) Continuous LhtTesMMa*-- Lfst Ad hems RegwnM CurerbM (YKYtde ftwiouslP Usted UmmTected Itmtsjr To the best of m knowledge, the work inspected was in accordance with the Building Division approved design drawings, specifications an�aoolicable workmanship provisions of the U.B.C. except as noted above. Special irapectorSignattm Uatin Print Full Name: Newport Be ich.Regaha ' NW speciapnspeaionneport au/m/Zp1E ;(--,1le 67 Continuous Inspection c% Materials Testing SOUTHWEST IWCOlwOOOOOOOOOCO Inspection TCStlllg„ Inc. 441 Commercial Way, La Habra, CA 90631-6168 (562)941-2990 - (714)526-5441 FAX (562)946-0026 FIELD DATA ON TEST SPECIMENS --- ASTM C31, C138, C143, C172, C173, C231, C1064 --- CONCRETE: X MORTAR: SHOTCRETE: CORES: GUNITE: ADDRESS: 124 24, NEWPORT BEACH JOB M DATE: 04/21/2022 JOB NAME: PERMIT M 2021 3113 ISSUED BY: ARCHITECT: RICARD DESIGN ENGINEER: 1-2ASSOCIATES CONTRACTOR: OWNER / BUILDER SUB: , LOCATION IN STRUCTURE: SLAB / FOOTINGS TRACT: PHASE: LOT M CONCRETE SUPPLIER: GARY BALE PLANT: MIX #: 14671 TYPE OF CEMENT: ADMIXTURE: TICKET M 348444 SLUMP: 4.00 in. WATER ADDED: 0 gal. AIR TEMP: 0 F CONCRETE TEMP: 70 F MIXING TIME: 25 min. TIME CAST: 10:00 DATE CAST: 03/24/2022 RECEIVED AT LAB: 03/28/2022 SPECIMENS MADE BY: STEPHEN BOOTH SPECIFIED PSI @ 28 Days: 3000 LAB M 203056 CLIENT: STEPHEN BOOTH INSPECTIONS TESTING INFORMATION: SAMPLE IDENTIFICATION: 2269898 2269899 2269900 %GE DAYS: 19 28 28 DATE TEST: 04/12t2022 04/21/2022 04/21/2022 SIZE (in ): Height X Diameter 8.000 X 4.000 0.000 X 0.000 0.000 X 0.000 AREA (in.A2): 12.57 CRUSH LOAD (lbs.): 64140 ` COMPRESSIVE STRENGTH (psi.): 5100 HEIGHT -DIAMETER RATIO: CORRECTION FACTOR: CORRECTED STRENGTH (psi.): BREAK TYPE: II 1 I C.T.M. USED: Fomey96 Fomey96 Fomey96 REMARKS: ASTM C39, C174, C192, C470, C617, C42 COMPLIES: DOES NOT COMPLY: FOR INFORMATION: X THIS REPORT SHALL NOT BE REPRODUCED, EXCEPT IN FULL, WITHOUT THE APPROVAL OF SOUTHWEST INSPECTION AND TESTING, INC. SAMPLES CAST BY OTHERS: NOTICE:These test results are from samples cast by inspectors or technicians not employed by our firm. They were either delivered to our laboratory or picked up by our driver. We will accept no responsibility for the Inspection made on the jobsite by the inspector, furthermore we do not take responsibility for any Information on this report other than the strength as tested and reported. 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