HomeMy WebLinkAboutPASADENA AVE 175 01/04/2018CITY OF TUSTIN PAID
Community Development Department — Building Division
300 Centennial Way, Tustin CA 92780 JAN U 4 2018
Building Counter (714) 573-3131— Inspection Recorder (714) 573-3141 CITY OF TUSTIN
CASHIER
BUILDING PERMIT NUMBER: B2017-0427 ADDRESS: 175RASAENA AV TUST SUITE
ASSESSOR'S PARCEL NUMBER:
LOT NUMBER ................................
:
DEVELOPMENT AREA ...............:
PROPERTY OWNER .....................:
CONTRACTOR
STOLL CONSTRUCTION
21151 BRLARWOOD LANE
TRABUCO CANYON, CA 92679
(949)933-7064
ocmmiNly ft+wptnant mepmun"
401-541-08 Srdi45t?i1k'"!i
Aft
TUSTIN ►miaNO wok rccr.nrvnv 1iA.rntr,1 (CrQ/y1010t1)-t�t.l�
nsTF IS SUED : 01/04/2018
KOZLIK DAVID W C====
ft nmwa•�cpdainw Gq
175 PASADENA AVEyft Oft "too
TUSTIN CA 92780-2914 RN6a 'Si\'1
JOB DESCRIPTION: REPLACE ALL
Maeopterai rtXn O t. tilt," Ca WW* DNanpnyn raow wft
aNaMMlaMi dq:
rtrw�xr MnkbMCanr aa«trrapaa,gn
waver
'0
OnipuW CuiueY .tid lM,ti�UILt.
ttr Wq- Wworks nrmwift. oi,& nip.a�antlNro.in
aopropiaiaN�� of-016MI. tryst r+awn. t aq1 uw b nw
Wwftw"m *irt`aapngY�bgbYnO Wod,W" xm-ws aMM
turtft'. ni r14ni. ` .
(13 WINDOWS TOTAL)
LICENSED CONTRACTOR DECLARATION:
I hereby affirm that I am a licensed Contractor under the provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code, and my license
LICENSE NUMBER: 675254 LICENSE CLASS:
Expires DATE:02/28/2019
OWNER BUILDER DECLARATION:
I hereby affirm that I am exempt hour the Contractor's License Law for the following reason (Section 703 1.5, Business Professions Code: Any City or county which requires a perm
structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Coutractor's License L
3 of the Business & Professions code] or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit sr
hundred dollars ($500.00).
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 (Section 7044, Busi
not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or tbrough his or her own employees, provided that such improvemem
building or improvement is soldwithin one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purposes of sale).
_ —.I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business & Professions Code: The Contactors Lice
or improves thereon, and who contacts for such projects with a contractor(s) license pursuant to the Contractors License Law).
I am exempt under Section Business & Professions Code for the following reason(s):
Owner Signature: Date:
WORKERS' COMPENSATION DECLARATION:
1 hereby affirm under penalty of perjury one of the following declarations:
I have and willmaintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the wr
I have and will maintain Worker's Compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
Number are:
POLICY NUMBER 9011879 COMPANY: STATE FUND
(This section need not be completed if the permit is for one hundred dollars ($100) or less).
I cert at rm�� performance of the work for which this permit is issued. I sha not employ any person in any manner so as to became subject to the Worker's Compensal
suhject to the l er's.Comnensa mus of Section 3700 of the Labor Code s all rthwith comply with those provisions.
WARNING:Failure ti) secure Worker's -C' omp'basation coverage is unlawful, and shall inject an employer to criminal penalties and civil fines up to one hundred thousand. dollars (:
as provided for in Section (3700) of the Labor Code, interest and attorney fees.
IMPORTANT:
Application is hereby made to the Building Official for a permit subject to the conditions and restrictions set forth on this application. Each person upon whose behalf this applicafi,
benefit work is performed under or pursuant to any permit issues as a result of this application agrees to, and shall, indemnify and hold harmless the City of Tustin, its officers, agen
Chapter 2 of the Uniform Administrative Code. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection has been received I certify
information is correct. I agree to comply with all City and State laws relating to the building construction, and hereby authorize representative of the City to enter upon the above in
sr. Contractor. or Authorized A Date
% 1 O
PERMITS ARE SUBJECT TO IRA ION IF WORK COMMENCED AFTE
180 DAYS R DATE
OF ISSUANCE OR IF WORK IS SUSPENDED FOR 180 DAYS*-'
O.C.F.A. Number.........:
OCCUPANT LOAD:
0
OCCUPANCY GROUP:
R
CONSTRUCTION TYPE.:
RESIDENTIAL SQ.FT:
0
COMMERCIAL SQ FT:
0
INDUSTRIAL SQ FT: 0
GARAGE SQ FT:
0
OFFICE SQ FT:
0
- WAREHOUSE SQ FT: 0
ROOF SQ FT:
0
TENANT IMPR. SQ FT:
0
OTHER SQ. FT: 0
NUMBER OF UNITS:
1
NUMBER OF STORIES:
0
CBC EDITION: 2016
NUMBER OF SEATS:
0
VALUATION...:
$0.00
BUILDER VALUATION:$15,000.00
FEE SUMMARY
PLAN CHECK
$140.22
BUILDING PERMIT:
$235.31 PUNINSP.:
$40.06
MECH PERMIT:
$0.00
PLUMBING PERMIT:
$0.00 ELEC PERMIT:
$0.00
SIGN PERMIT:
$0.00
GRADINGPERMIT.
$0.00 PRIVATEIMPR:
$0.00
NEW DEV. TAX:
$0.00
TSIP ZONE A FEE:
$0.00 TSIP ZONE B FEE:
$0.00
SMIPFEE:
$1.95
MICROFILM FEE:
$6.75 OCFAFF,E:
$0.00
PENALTY FEE.:
$0.00
REFUNDABLE BOND:
$0.00 MISCELLANEOUS:
$0.00
PIN REVIEW:
$28.04
TOTAL FEES:
$453.33
LICENSED CONTRACTOR DECLARATION:
I hereby affirm that I am a licensed Contractor under the provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code, and my license
LICENSE NUMBER: 675254 LICENSE CLASS:
Expires DATE:02/28/2019
OWNER BUILDER DECLARATION:
I hereby affirm that I am exempt hour the Contractor's License Law for the following reason (Section 703 1.5, Business Professions Code: Any City or county which requires a perm
structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Coutractor's License L
3 of the Business & Professions code] or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit sr
hundred dollars ($500.00).
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 (Section 7044, Busi
not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or tbrough his or her own employees, provided that such improvemem
building or improvement is soldwithin one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purposes of sale).
_ —.I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business & Professions Code: The Contactors Lice
or improves thereon, and who contacts for such projects with a contractor(s) license pursuant to the Contractors License Law).
I am exempt under Section Business & Professions Code for the following reason(s):
Owner Signature: Date:
WORKERS' COMPENSATION DECLARATION:
1 hereby affirm under penalty of perjury one of the following declarations:
I have and willmaintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the wr
I have and will maintain Worker's Compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
Number are:
POLICY NUMBER 9011879 COMPANY: STATE FUND
(This section need not be completed if the permit is for one hundred dollars ($100) or less).
I cert at rm�� performance of the work for which this permit is issued. I sha not employ any person in any manner so as to became subject to the Worker's Compensal
suhject to the l er's.Comnensa mus of Section 3700 of the Labor Code s all rthwith comply with those provisions.
WARNING:Failure ti) secure Worker's -C' omp'basation coverage is unlawful, and shall inject an employer to criminal penalties and civil fines up to one hundred thousand. dollars (:
as provided for in Section (3700) of the Labor Code, interest and attorney fees.
IMPORTANT:
Application is hereby made to the Building Official for a permit subject to the conditions and restrictions set forth on this application. Each person upon whose behalf this applicafi,
benefit work is performed under or pursuant to any permit issues as a result of this application agrees to, and shall, indemnify and hold harmless the City of Tustin, its officers, agen
Chapter 2 of the Uniform Administrative Code. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection has been received I certify
information is correct. I agree to comply with all City and State laws relating to the building construction, and hereby authorize representative of the City to enter upon the above in
sr. Contractor. or Authorized A Date
% 1 O
PERMITS ARE SUBJECT TO IRA ION IF WORK COMMENCED AFTE
180 DAYS R DATE
OF ISSUANCE OR IF WORK IS SUSPENDED FOR 180 DAYS*-'