13812 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
as
_, BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING ' 1161(Lot3 Forest S r,i n Court APPLICATION & PERMIT
ADDRESS P 9 13 812
110 - pip-,Y, BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME OTY. ELECTRIC PERMIT FEE
Gregory Group, Inc. , D„595-2100
CONTRACTORS `� UTLETS
NAME -SWITCHES-RECEP 10.0011.00
Gregory Group, Inc. ,.,.. 430097 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS a Q C TA win Dolphin Dr. 3 APPLIANCES-RESIDENTIAL 4.00
"My
L /S
ReaWood C1 y, C PHONE 595-2100 ( PANELS 10.00 JD DATE OF APPLICATION
ORRCHrtECT Aram Ba$senian, A. I .A. & PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .C.NO.
ENGINEER Associates
uc.ND. SIGNS TRANS. 3.00
ARCH,OR ENO. SPECIAL CIRCUIT 5.0.0 PP-9.11111
VA❑DATION
ADDRESS -990 Westerly Place, 6/170
Newport-Beach, CA zIr 9 660 EMP.METER OR POLE INS. 20.00
APPLICANTS Ly JA 94U�7 MOTORS SEE FEE SCH. oy-yx/(s
APPLICA 2 C 11, in him Dr.
Redwood 1 SERVICE CHANGE 20.00
o0Z �
'. 02 LICENSED COM'RACf0R5 DECLARATION
o u 1 hereby oflirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y (commencing with Section 7000)of Division 3 of the Business and
H D 2 Professions Code,mod my license is in full force aqJ,� t BLDG. ELECT. PLG. MECH.
Z Ou, License Cl:Lss D Lic.Number 4.JU1J}y �-
o Z F o Datc Contractor.
BUILDING PERMIT
re ¢ c OWNER-BUILDIiR DECLARATION
w v INFORMATION
wa N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
FLLog Law for the following reason,(See.7031.5,Business and Professions PERMIT ISSUANCE 1000 VALUATION $/FT.
Code:Any city orcounty which requires a Permit to conslmcl,4ilcr,
2 S
40 improve,demolish,or repair any structure,prior to its issuance,atm ELEC.CONTE. LIG N0. ELEC.
DLL requires the applicant for such permit t0 rite a signed statement that TOTAL PERMIT TO
r = he is lice pursuant to the provisions of the Contractors License
i
Law(Chapter 9(commencin with Section 7000)of Division 3 ofthe
- Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
Sthe bleu for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; by any applicant fora Permit subjects SSOO)plicantteacivil penally ALTER-DRAIN -WATER (EA.) 5.00 C� S �/Velma
of not more than fore permit dollars(551X1).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure B not OCC.GROUP RES.UNITS
intended or offend for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA,COND. N00-0
.00
Code:The Contractor's License law does not apply to an owner of
• property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP S.oO 6Q FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsI are not intended of offered for sale,If,however,the building
or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 Rs IND CON PB Dmer
❑ 1,as owner of the properly,am exclusively contracting with ❑ El 11 IDlicensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSE RS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 34 �- 3/l
contracts for such projects with a mmmeton s)licensed pursuant to
the Contractor's License Law. J SEWER-SANITARY-STO RM EA.200ft/10.00 D TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 `7pC �
0 on / / /
Owner Date 1 WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent m self-insure, - ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(sec.3800,lam.C.)United Pacific Rel
Policy No, Company
O ❑ Certified copy is hereby furnished. FIRE SPR I NK ENERGY T74
Z 2 ❑ Certified cop the city inspection division.
F O Applicant _ MISC.- REFER TO ORD. Y❑ N❑ Y ❑ No
w PERMIT ISSUANCE 10.00
CHRTII'ICA -.OP IiXEMPTION PROM WORKERS' FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLO.CONTE. LIC.NO, PLG.
Z (This section need not be completed if the permit Is for one TOTAL 3 Y❑ N❑ Y❑ N❑
hundred dollars IS 100)nrI..)
U O 1 certify that in the Performance of the work for which this Per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U rs
mit is issued,I shall not employ any peon in any manner so as to
become subject to the Workers'Compensation laws of California.
U W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE'10 APPLICANT: IL after making this Certificate of Ex-
f" ? emptier,you should become subject In the Workers'CompensationAPPLIANCE 5.00 PLAN CHECK /- Sj
Provisions of the labor Code, you must forthwith comply with FEE v /
U such provisions or this Demlil shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO)000C.F.Ii 6.00 SEISMIC FEE /00/
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec I-
(We)
3097.civ.cl. Security Pacific HEATING UNIT(TO 100,000B.T.U.) 8.00
Lender's Name HEATING UN IT 100,000 B.T.U.)9.50Lender's Address_S��19anc-i-sC�A-I certify that I have read thisapplication and state that the above VENTILATION FAN (SINGLE) 4.00information u correct. I agree to comply with all city and county ordinances and state laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 11X1,000 BTU)SEE FEE SCH.above-mentioned property for inspection purposes.(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. FCupertino against liabilities,judgments, casts and exptaises whih PERMIT ISSUANCE IO,pO Omay in any way accrue against said City in consequence of the grntinggood ofl� MECH.CONT. LIC.NO. MECH.
�����Slgmdc ppImant/CmmUctor e
FFICE COPY