B20-0423 - 27152 PASEO PEREGRINOCITY OF SAN JUAN CAPISTRANO
BUILDING PERMIT
Permit No. B20-0423
08/18/2020
ISSUED
JOBVALUE
NO_UNITS
Permit Number
ISSUED_BY
SITE_APN
SITE_LOT_NO
SITE_TRACT
SITE_SUBDIVISION
PERMIT TYPE.
OCCUPANCY_TYPE
BUILDING _SF
NO_STORIES
DB1
675-201-15
22
$ 2,500
BUILDING
0
2
0
JOB ADDRESS: 27152 PASEO PEREGRINO
SAFAVI, NAZILAOWNER NAME
27152 PASEO PEREGRINOMAILING ADDRESS
CITY,STATE,ZIP
CONTRACTOR NAME
ST. LIC EXPIRE
ADDRESS
ST. LIC #
CITY, ST, ZIP
TENANT NAME
PHONE #
MAILING ADDR
CITY, ST, ZIP
PHONE #
CITY, ST, ZIP
MAILING ADDRESS
ST LICENSE #
ARCH/ENG/DESIGNER
I have carefully examined the completed permit application and do hereby certify under penalty of
perjury that all information hereon including the declarations are true and correct and I further
certify and agree if a permit is issued: to comply with all City, County, and State laws governing
building construction, whether specified herein or not. I also agree to save, indemnify and keep
harmless the City of San Juan Capistrano against all liabilities, judgments, costs and expenses
which may in any way accrue against said City in consequence of the granting of this permit.
Owner/Contractor Nazila Safavi
Print Name
Applicant's signature
Owner builder
PLUMBING PERMIT AMOUNT
MECHANICAL PERMIT AMOUNT
MOBILE HOME PERMIT AMOUNT
Expiration: Every permit issued by the Building Official under the provisions of this Code shall expire by
limitation and become null and void. If the building or work authorized by such permit is not commenced within 180 days from the date of such permit, or if the building or work authorized by such permit is
suspended or abandoned at any time after the work is commenced for a period of 180 days.
An OSHA permit is required for excavations over 5’0” deep and demolition or construction of
structures over 3 stories in height.
_____Contractor:I hereby affirm that I am licensed under provisions of Chapter 9 of Division 3 of the Business and Professions Code, and my license is in full force and effect.
_____Owner/Builder: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. (Sec.7044, Business and Professions
Code: the Contractor’s License Laws does not apply to and owner of property who builds or improves thereon, who does such work himself or through his employees, provided that such improvements are not
intended or offered for sale. If however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale)
______Owner/Builder:I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor’s License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractor’s) license pursuant to the Contractor’s License Law.
_______ Workers Compensation-I hereby affirm under penalty of perjury one of the following declarations:I have and will maintain workers’ compensation insurance, as required by Section 3700 of the
Labor Code, for the performance of the work for which this permit is issued. My workers’ compensation insurance carrier and policy number are: Carrier__ Policy# (This section needs to be completed if
the permit is for one hundred dollars($100) or less)
AMOUNTELECTRICAL PERMITDESCRIPTION
_______ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers’ compensation
laws of California and agree that if I should become subject to the workers’ compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
WARNING:FAILURE TO SECURE WORKERS’COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TI CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSDAND DOLLARS($100,000) IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY’S FEES.
B20-0423 ELECTRICAL ISSUANCE FEE 27.24
EXTEND ELECTRICAL 5.26
RECEPTACLE SWITCH AND LIGHT OUTLETS 8.54
Total Electrical 41.04
Total Plumbing
APPLIANCE VENTS 8.03
EXTEND DUCTWORK 8.03
MECHANICAL ISSUANCE FEES 27.24
Total Mechanical 43.30
Total Mobile Home
,
,
,
SAN JUAN CAPISTRANO, CA 92675
193sf ADDITION FROM ENCLOSED PATIO
PHONE
PHONE
Date _________________ Applicant _______________________________________
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NO FINAL INSPECTION CALLED
EXPIRED 08/18/21
Date:
Permit No.
Applicant:
Phone/E-Mail
Job Location:
CITY OF SAN JUAN CAPISTRANO
BUILDING PERMIT FEES
Account # Type Cost
01-44221 Building Permit
01-44223 Mechanical
01-44224 Plumbing
01-44225 Electrical
01-44221 Mobile Home Permit
01-44222 Grading Permit Fee
01-44231 Grading Plan Check
01-44222 On-Site Residential Permit
01-44231 On-Site Residential Plan Check
Subtotal
01-44230 Bond Processing
01-44230 Building Plan Check
01-44230 Additional Plan Check
01-44230 Digital Record Fee ($1.00 per sheet)
01-44221 C & D Administrative Fee
01-44221 Special Inspection-Reinspection
01-44222 On-Site Commercial/Tract Permit Fee
01-44231 On-Site Commercial/Tract Plan Check Fee
01-44214 Geotechnical Soils Plan Review
10-44320 Ordinance 211
10-42510 Ordinance 364
01-45354 Copies @ .20 Each
90-23331 SMIP Fee
33-44370 H.O.P.E. Fee (Housing in Lieu)
Other Fees
TCA Fees Date Received
HOA Approval Date Received
School Fees Date Received
Engineering Fees Date Received
Water Division Fees Date Received
01-44221
01-44221
01-44240
90-23000
90-23000
TOTAL FEES PAYABLE TO CITY OF SAN JUAN CAPISTRANO
Receipt # _________ Date: ______________ Cashier: _____________________________
Refundable Bond/Deposit Posted by ______Owner_____Contractor ________Type
Title 24 Energy Provision (20% Permit Subtotal & Bldg Plan Check))
Title 24 ADA Fee (10% Permit Subtotal & Bldg Plan Check)
Refundable Bond/Deposit Posted by ______Owner_____Contractor ________Type
NPDES Permit Fee (10% Permit Subtotal)
$ 118.90
$ 41.04
$ 43.30
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$ 86.93
$5.70
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.50
$0.00
$ 18.33
$0.00
$ 20.32
$ 394.04
8/18/2020
$ 729.06
$0.00
$ 203.24
8/18/2020
B20-0423
SAFAVI, NAZILA
27152 PASEO PEREGRINO
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✔
193sf
2,500 SFR
Jesse Lara
626 523-5270
globemrg@gmail.com
27152 Paseo Peregrino Ave
193SF addition. Enclose existing 193SF patio.
Nazila Safavi
27152 Paseo Peregrino Ave
San Juan Capistrano, CA 92675
949 295-2709
Jesse Lara
337 w. 2nd St
San Dimas, CA 91773
626 523-5270
5
05-11-2020
B20 0423
REV 04/18
PAGE 1 of 2
PROPERTY OWNER'S PACKAGE
DEVELOPMENT SERVICES
Building and Safety
[Disclosures and Forms for Owner-Builders Applying for Construction Permits]
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at .
We are providing you with an Owner-Builder Acknowledgment and Verification of Information 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-BUILDER ACKOWLEDGMENT AND VERIFICATION OF INFORMATION
Please read and initial each statement below to signify you understand or verify this information.
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an Owner-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 on my property.
2. I understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an Owner-Builder I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or
her name instead of my own.
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.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, 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 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 by these laws may
subject me to serious financial risk.
7. I 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 Contractor.
8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held 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.
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REV 04/18
PAGE 2 of 2
PROPERTY OWNER'S PACKAGE
9. I understand I may obtain more information regarding my obligations as an “employer” from the Internal
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 more information
about licensed contractors.
10. I 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. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by
all applicable laws and requirements that govern Owner-Builders as well as employers.
12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any 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 agency responsible for issuing the permit.
NOTE: A copy of the property 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 SIGNATURE DATE
NOTE: The following Authorization 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
AUTHORIZED AGENT NAME PHONE
AUTHORIZED AGENT ADDRESS
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 SIGNATURE DATE
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7.15.2020
7.15.2020