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PLEASE PRINT <br />PROJECT ADDRESS: <br />USE OF BUILDING: <br />CITY OF SANTA ANA <br />BUILDING PERMIT APPLICATION WORKSHEET <br />2102 North Tustin Avenue SUITE: N.A. <br />RESIDENTIAL X COMMERCIAL INDUSTRIAL OTHER <br />3/2/05:forms/Blda.ADP.Worksheet <br />SAPIN #10 1 71794 <br />MASTER ID# <br />NATURE OF WORK XNEW ADD ALTER/T. I.DEMO REROOF REPAIR SIGN MISC <br />RIEW/ADDITION/Al TERATION· <br />4 1 ST FL.5,580 SF BASEMENT: YES/NO <br />N.A. <br />r 2ND FL.SF PATIO/ENCL. PATIO: <br />TOTAL OF OTHER FLS:None SF RES. REMODEL: <br />N.A. <br />GARAGE/CARPORT:SF ALTEFUT.I.: <br />NO <br />N.A. <br />N.A. <br />N.A. <br />SF NO. OF STORIES: <br />SF BLDG. HEIGHT: <br />SF PROPOSED USE: <br />SF <br />ONE <br />33'-11 1/2" <br />Retail/Prof. <br />JOB DESCRIPTION (non-residential projects see reverse side of this ap,licationh: New pingle story retail/ <br />professional building on grade.hikt 59*14-4, <br />BUILDING OWNER'S NAME:Modj Rajaeeyan <br />ADDRESS: 2 3 55 Pieper Lane <br />TENANT'S NAME (Comm/Ind):None <br />CONTRACTOR'S NAME: None selected. <br />ADDRESS: <br />WORKERS COMP. POLICY#EXP. DATE: <br />ARCHITECT/ENGINEER: Synergy Architecture <br />ADDRESS:9701 Wilshire Blvd.,Ste.1000 <br />CONTACT NAME:John Siebel <br />CITY:Tustin <br />STATE CONTR. #: <br />CITY: <br />INSURANCE COMPANY: <br />STATE LICENSE #: C-8393 <br />CITY: Beverly Hills <br />PHONE NO: 310 <br />PHONE NO:949-929-2630 <br />STATE: CA ZIP:92782 <br />PHONE NO:N.A. <br />LICENSE CLASS:PHONE NO: <br />STATE:ZIP: <br />SANTA ANA BUS. LlC. #: <br />PHONENO: 310-962-3252 <br />STATE: CA ZIP: 90212 <br />-962-3252 <br />E-MAIL KDDRESS:jes@synergyarchitecture.com <br />OFFICE USE ONLY:ACC OR SPC (CIRCLE ONE)HRS PER BLDG. FEE $ <br />ly&, €OCC. GROUP:RECEIPT #(poDa-3-P/C FEE PD $ , <br />TYPE OF CONSTR:VALUATION: $11 Mob SUBMITTAL DATE: <br />FIRE SPKR: YES / NO A/C: YES / NO FLOOD ZONE:PROCESSED <br />RES. DEV. FEE: YES / NO PRIOR DWELLING UNIT: YES / NO COMMENTS: <br />A / blf¥\A -/2.-40·41 <br />PLANNING OK TO CHECK & DATE „4:/'27 V / ' 4 BLDG. DEPT. APPROVAL & DATE <br />PLNG CONDITIONS: <br />12- ' 4/L <br />lott