15136 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN.ONLY 17
@Ul LDING PROJECT IDENTIFICATION PERMIT NUMBER -
BUILDING APPLICATION &PERMIT 15136[� �(�
ATR a 15675 WALNUT SPRING COURT BUILDING-ELECTRICAL-PLUMBING-MECHANICAL I J U
N11MER6 Gregory roup, Inc. PLAN CHECK VALIDATION
Ahmanson Dev. 415-595-2100 DTV. ELECTRIC PERMIT FEE
PX NE
CONTRACTOR'S
NAME UTLETS-SWITCHES-RECEP 10.00/1.00'
Gregory Group, Inc.IJCNB- 43009 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S _
AD{{B�$i C TWIr„� r�+�0 PPLIANCES-RESIDENTIAL 4.00
KWIr924a�5 41 JPH NE�-�i8�• PANELS 10.00 DATE OF APPLICATION'
ORRCHITECT ram, ssenian, PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER Assoclaes - C-83 5
Llc.NO, ISIGNS TRANS, 3.00
ARCH.OR ENG ` , PERMIT VALIDATION
ADDRESS Orchard Dr. /{)100 SPECIAL CIRCUIT 5:00
Santa Ana Hts. CA. TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS . SEE FEE SCH.
AP
Twin Dolphin Dr.RWC9406 SERVICE CHANGE 20.00
02 LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that 1 on licensed under provisions of Chuptm 9 nEC 13
¢e, w ISSUANCE DATE_
w a (commencing with Section 7000)Of Division 3 Of the Business and - BLDG. ELECT. PLG. MECH.
F w i Professions Cosg,and my license is in full fa�r4l q9T�-
o T m a License Class Lia Number / r-
r 1e r j Date_Contractor C1�f off Cuperfla
a m S LI luJ BUILDING PERMIT
¢ ¢ a
OWNER-BUILDER DECLARATION '
aau u INFORMATION
w ;LL s- 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
r
It.0 Law for the following reason.(Sec.703 1.5,Business and Professions VALUATION S/FT.
H PERMIT ISSUANCE 10.00
Code:Any city or county which re,mucia permit to construct, 105 B65 y
¢ 2 ¢0 improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. I.G.NO. ELEC. O ,O V
o n, requires the applicant for such permit to file a signed statement that TOTAL
6 W m,r, he is licensed pursuant to the provisions o1'lite Contractor's License PERMIT TO -
FZQ Law(Chapter9icrnnmencingwithSection7000)ofl)ivision3ofthc SF,DD
E 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢R $ the basis for the alleged exemption.Any violation of8ection 7031.5 STORIES TYPE CONSTR.
a; - by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).): 2 5NHR
❑ I,as owner(11 the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is nal 1
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 R-3
Code:The Contractor's License Law does not apply to an owner of
properly who builds Or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employers,Provided however,
such improve.
meptshimself
f o through
ot nItis or offered res,or provided that such
he building GAS•EA.SYSTEM-1 1NC.4 OUTLETS 6.00 2917
or improvement is sold within line year of completion,the owner GAS-EA.SYSTEM-OVER 4 IEA.) 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 RES IND CON PB- Omer
❑ 1,as owner of the property,ant exclusively contracting with ® ❑ ❑ El ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(,)licensed Pursuant to P /
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1amexempt tinder Sec. ,H.&P.C.for'this WATER HEATER ADVENT 6.00 8088
reason
Owner Date WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
WORK Ii RS'COMPENSA'f10N DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm Ih:n I have a certificale oI consent to self-insure, ZONING ENG.SITE NO.
or a certil icaie of Workers'Compensation Insurance,or a certified
copy thereof(Sce.3800,Lab.C.), United Pacific
Policy No. Compuny
O ❑ Certified copy is hereby initiated. FIRE SPRINK ENERGY T-24
Z Z Q o'lified copy is f wit) the city inspection division.
Q A . MISC.- REFER TO ORD. Y ❑ IN Y ❑ N❑
cc6) - CERTIFICAH: F EXEMPTION PROM WORK ERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C:
Lel COhIPENSAT'ION INSURANCE PLG.CONTR. LIC.NO, PLG,
Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y [:] N❑
hundred dollars($100)or less.)
U O -I certify that in the performance of the work for which thisper OTY MECHANICAL PERMIT FEE FEE SUMMARY
IL U mil is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
BIG Uate Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ggD.SD
} to NOTICE TO APPLICANT: If,after making this Certificate OI E.
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE 15.50
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1OPMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency]or EXHAUST HOOD (WITH DUCT) 5.00
the performance (Ir�l e work Jr r whip)this•pXrpon is issued(Sce. - MICROFILM
3097,Cie.C.). JeCUrl Ly Yac ST1C HEATING UNIT ITO 100,000 B.T.U.) 8.00 -
Leuder'sName adero HEATING UNIT 100,000 B.T.U.)9.50 70.35
Lender's Address a.r V re f ELECTRIC
'I certify that I dove read this application and state that the above VENTILATION FAN (SINGLE) 4,00
information is correct.I agree to comply with all city and county PLUMBING 70.35
ordinances and state laws relating to building construction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above n entioned property for inspection purposes. 70.35
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. 2C),7-0-3
g9' O�
an
Cupertino against liabilities,judgments, costs and expenses nswhich PERMIT ISSUANCE 10.00 CONST.TAX L
may in y way accrue against said City in comwquence of the
ranting of this Perm it l/ like MECH.CONT. LIC.NO. MECH. r
!� /L1lik
TOTAL TOTAL
Signature of APPhca odor-fir bale,
OFFICE COPY