002416 (BLCK)P.O. BOX 1504 N O . 002416
Building 54'- 493 Hila. LA QUINOTACCALIFORNIA 92253
Address
Owner
BUILDING: TYPE CONST. OCC: GRP.
Mailing
Address 7r_()3 VX, A.P. Number
City I Zip Tel.
s 9=60. -%8-2WS Legal Description
Contractor Project Description 11=1 PHAW 4. A
Sswai 1s 'qtr gss :Z Tare =-e W.Us throughout phase.
CityZip Tel."
State Lic. City
& Classif. 28.8130 Lic. # 326 Sq. Ft. 4.5-7 No. No. Dw.
Size Stories Units
Arch.; Engr., , -
Designer New q Add ❑ Alter ❑- Repair ❑ Demolition ❑
Address Tel.
CityZip State
Lic. #
_ LICENSED CONTRAQTOR'S DECLARATION
tiereby affirm that I am licensed.under provisions of Chapter 9 (commencing with Section
7000)"of Division 3 of the Business and Professions -Code, and my license is in full force;and
effect. ; �'v..i.f;� il`:.. �" ✓ , /? -;t
SIGNATURES ! : ! DATE
i OWNER-61UILDER DECLARATION ES1lmated ValUatlOn
I hereby affirm that I am exempt from the Contractor's License Law for the following Ii.00
reason: (Sec. 7031.5,Business and' Professions Code: Any city or. county which requires ;a
Permit to construct, alter, improve demolish, or repair any structure, prior. to its issuance also
requires the applicant for such,p`ermh to file a signed statement that he 4s licensed pursuant to __ PERMIT AMOUNT
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000)' of
Division 3 o'f the Business and Professions Code, or that. he is ekempt therefrom; and the basis -
for. the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit .Plan Chk. Dep. Aa q
'subjects the applicant to a civil penalty of not more than -five hundred dollars ($500).' Plan ChkBal., s
.. ❑ I, as owner .
of the property; or my employees with wages as their sole compensation, will.cp�tS '
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const. 92a50
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work - himself or through - his own employees, Mech. -
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 Electrical
,. of proving that he did not build or improve for the purpose of sale.) -
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing
struct 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 S.M:I.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)' -. -
❑Lam exempt under Sec.. B. & P.C. for this reason Grading
Driveway Enc.
Date owner Infrastructure
WORKERS' COMPENSATION DECLARATION
'I hereby affirm that -I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company -
❑ Copy is filed with the city. O certified copy is hereby furnished. , .
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
- , WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is. for one hundred dollars (5100) valuation -
or less.)
I certify that in the performance of thg 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.
Date "' Owner '
NOTICE TO APPLICANT. If, after making this Certificate of Exemption you should become - ZONE:- BY:. _
subject 'to the Workers' Compensation provisions of the Labor Code, you must forthwith . Minimum Setback Distances: -
comply with such provisions or this permit shall be deemed revoked.
Front.Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center. Line
I hereby affirm that there is a construction lending agency.for the performance of the - -
work for which this permit is issued. (Sec. 3097, Civil Code.) Side Setback from. Property Line '
Lender's Name
Lender's Address FINAL DATE INSPECTOR
This is a building permit'when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.^��
I certify that I have read this application and state that -the above information is correct. Issued by: Date Permit
I agree to comply with all city and county ordinances'and state laws relating to building
construction, and.; hereby authorize representatives sof this city to enter the above-:
mentioned property foNnspection purposeAs.. , Validated by:
Signature of applicant /�:% ! �--P' Date 17`
Mailing Address "r ' . 114 -*' " Validation:
City, State, Zip
A 5 8 1 3 6 17 i 53.43 �K
HARD COPY
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. @ $
2ND FL. SQ. FT. @
POR. SO. FT. @
GAR. SO. FT. @
CAR P. SQ. FT. @
WALL SQ. FT. @
SO. FT. @
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APP./EQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
KITCHEN SINK
ABSORPTION SYSTEM. B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE,TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. @ c
BATH TUB
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. aESID @ 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR @ 3/ac
HOUSE SEWER
REMARKS:
VENTILATION
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSYtuI V Wb -WUNA i Untb11N1 i IAw,
GARDEN WALL FINAL