002922 (BLCK)P.O. BOX 1504 N-0. 0 2922
Building- ,,,� LA QUINOTACCALIFORNIA92253
Address ' 'til •
Owner
Namid Bailey
BUILDING; TYPE CONST. OCC: GRP. '
Mailing ,
Address P.O. B= 932 A.P., Number
City Zip Tel.
M xsil,a 92253 564.1346 . Legal Description
Contractor Project Description
Address.
S
City "' Zip Tela
Sam
9.
State Lic. City 161 6�
8 Classif. Lic. # Sq. Ft. JJla � No. No. Dw.
Arch., Engr., _ _ .
Size ' -
.No
-Units
Designer New ❑X Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
City Zip State
Lic: # r�
feMM
LICENSED.CONTRACTOR'SDECLARATION
�E��i
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.
SIGNATURE DATE
OWNER -BUILDER DECLARATION Estimated .VdlUatlOn c sry 1
I hereby affirm that I am exempt from the Contractor's License Law for the followings •�Pr^^°� ���1��
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 permit to rile a signed statement that he -is licensed. pursuant to --PERMIT AMOUNT ,
the provisions of the Contractor's License Law, Chapter 9.,(commencing with Section 7000) of
'Division '3 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 .permlt .Plan Chk. Dep.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
., ❑• I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale'. (Sec. 7044; Buisness and Const.SJs�
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 contractors) licensed pursuant to the Contractor's License Law.)
Grading
O I.am exempt under Sec. B. & P.C. for this reason
Driveway Enc..
Date Owner V Infrastructure
t
WORKERS' COMPENSATION DECLARATION
hereby affirm' that Ihave 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
.O Copy is filed with the city. . ❑ 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 ($100) valuation
or less.) -
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
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. 2-12-87
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 Date i
Mailing Address Validation:
City, State, Zip i1
A 7 3 3 8 2 17 20.00 U
HARD COPY
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® $
2ND FL.SQ. FT.
FOR. SO. FT. ®
GAR. SQ. FT, ®
CAR P. SQ. FT.
WALL SQ. FT. ®
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
7
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
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
BOND BEAM
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1+/a c
SEWAGE DISPOSAL
LUMBER GR.
SQ.FT.GAR ® 3/ac
HOUSE SEWER
FRAMING
FINAL INSP.
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
I-
TOTAL FEES
I
MICRO FEE
I I
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
,y
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
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