002120 (SATT)P.O. BOX 1504
Building 8€x-405 > LA QUINOTACCALIFORNIA92253
Address .
Owner
SM=dW
Mailing
Address 75—MJS M
City JZip Tel.
Contractor
NAS )twb*M and .rmd
Address.
City
State Lic. I City
& Classif. Lic. #
rucn., tnyr., .
Designer
Address Tel.
City Zip State
Lic. # ..
LICENSED CONTRACTOR'S DECLARATION
I hereby 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. �X l - r r - ft !/• f.
SIGNATURE' \� • ii DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason] (Sec. 7031.5,Business and Professions Code: Any city or. county "which .requires a
permlt_,fo construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to rile a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division3 of'the Business and Professions Code, or that. he is exempt therefrom, and'the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penafty'of not more than five hundred dollars ($500). '
O 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, Buisness and
Professions Code: The Contractor's License Law does notapplyto an owner'of property who '
builds or improves" thereon and who does such work himself or through his own 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 rovin that h d'md not build or 1m rove forth a o/ al
No. 002120
BUILDING: TYPE CONST. OCC: GRP.
,A.P. Number
,Legal Description
Project Description � PM 30
MG
Q
MG. 627
Sq. Ft. No. No. Dw.
Size Q1 Stories Units
New 4SL Add E3 Alter O Repair El. Demolition ❑
timated Valuation 103,665.50
PERMIT
Plan Chk.. Dep= •
Plan Chk. Bal.
Const.
Electrical
p . 9 a e _ p e purpos s e.)
O I, as owner of the property, am exclusively contracting with licensed contractors to con-
slruct 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 contractors) licensed pursuant to the Contractor's License Law.)
O I am exempt under Sec: B. 8 P.C. for this reason
Plumbing
S.M.I. .
Grading
Driveway Enc.
Date owner
Infrastructure
spa rpt+ Tye�t�
WA ,�yl„ys PA Frei` �fiii�s7 rd�c�r.7,tLa.
WORKERS' COMPENSATION DECLARATION
Thereby affirm that 'I have a certificate of consent to selVinsure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof: (Sec. 3800, Labor Code.)
Policy No. I Company
O.Copy is filed with the city. O Certified copy is hereby furnished.
I certify that in the performance of the work for which this permit is issued, I shall not
TOTAL
AMOUNT
m
114-.19
443.50
34.. OV
67 .41
87.50
.
CERTIFICATE OF EXEMPTION FROM
REMARKS
WORKERS'. COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
spa rpt+ Tye�t�
WA ,�yl„ys PA Frei` �fiii�s7 rd�c�r.7,tLa.
or less.)
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.
' 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
comply with such provisions or this permit shall be deemed revoked. -
Minimum Setback Distances: '
-
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.
3- S6
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 -of this city to enter, the above=
mentioned property for inspection purposes. ^„
Validated by:
Signature of applicant l ,1` .. "� Date «'��
Mailing Address
Validation:
City, State, Zip
A 4 5 6 5
3 6 231,$76 fl
HARD COPY
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE 3 Z aJ 4.
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. I SQ. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SQ. FT. ®
OTHER APP./EQUIP.
DRINKING FOUNTAIN
SQ FT ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT sC/Z ia /L
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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.
SQ. FT. @ c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 C
SEWAGE DISPOSAL
GAR. FIREWALL
SO.FT.GAR ® 3/ac
HOUSE SEWER
LATHING
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 3 �� .
7""/�ROUND PLUMBING �)
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE 3 Z aJ 4.
R OUGH PLUMB. y �6
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
/��1
SEWER OR SEPTIC
'
2IAOUGH WIRING 5;11 -11-OK
DUCT WORK
ROCK STORAGE
FOUND. REINF. l?/L �� �
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
REINF. STEEL s/27
GAS (FINAL)
TEMP. POLE
GROUT sC/Z ia /L
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM / Z7/�G�Z�G
WATER SYSTEM
GRADING
cu. yd.
I
$ pus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING S y/"X/ 0�7
FINAL INSP.
ROOFING t7 N/v
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND�; r O
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE_ FINAL
INSPECTOR'S SIGNATURESIINITIALS,
GARDEN WALL FINAL
D1--11'�14i/ %01F ff, te-