15815 (PLBG),. P.O. BOX 1504
Building 78-495 CALLE 53--%20 Ave Obregon LA OU NTA, CALIFORNIA TAMPICO2253•
Address'
Owner tOI & Vii. n 8 I5.tXe.
Address, 53-720, Ave .Obregon
City Zip Tel. " '
La-Quifata 92253 347-2366
Contractor
owner. Builder
gaoress
'ity Zip
State Lic. I City
&;Classif., . Lic. #'
Arch., Engr., .
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.: . - - .
SIGNATURE' .DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any.city, or county which requires a
permit to construct, atter, 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
Division 3 or 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 penally of not more than rive hundred dollars ($500). -
❑. 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 not apply to 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 proving that he did not build or bnprove for the purpose of sale.)
❑ I, as' owner of the property, am exclusively contracting with licensed contractors to con-
struct the,projecl. (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 1 am exempt under Sec B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
,(This section need not be completed if the permit -is for one hundred dollars ($100) valuation
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: H, after •making this Certificate or Exemption youshould. become
subject. to the Workers' Compensation provisions of. the Labor • Code, you must forthwith
comply with such provisions or this permit shall be deemed ievoked.
No. 15815-- "
BUILDING: TYPE'CONST. .00C: GRP.-
774115 . o i i—i
A.P. Number
Legal Descriptioii�'gt iid Block
188 Santa.;armeli�ta
C
Project Description ' 25 a 4 Ab5
sewe-Ir dry -line for
future ; i>. er tie-in.
. t
Sq. Ft..- No.
No. Dw e
Size Stories
Units.
New ❑:Add ❑ Alter ❑
Repair ❑, Demolition ❑
Estimated Valuation•:�Q�QO
ti
PERMIT -
AMOUNT
Plan Chk. Dep.
Plan Chk..Bal.., �.
Const:: j_ j -4301.00
Mech. ,
Electrical
Plumbing.
S.M.I.
Grading.
Driveway Enc.
Infrastructure -
TOTAL $ 0 ,, Cj 0
REMARKS"
ZONE: BY:
Minimum Setback Distances:
Front Set b�k4 o� Center Line
Rear Setb ca k from Rear Prop. Line
WARNING: FAILURE TO SECURE WORKERS'COMPENSATIONCOVERAGE ISUNLAWFUL, AND -- Side Street Setback from C rifer Line '
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
'HUNDRED THOUSAND DOLLARS ($100,000), IN 'ADDITION TO THE COST OF.COMPENSATION, Side Setback from-)Propopy Line ,
DAMAGES AS PROVIDED -FOR IN SECTION 3706 OF.THE LABOR.CODE, INTEREST, AND +,
ATTORNEY'S FEES.
This)), a building permit when properly filled out, signed and validated; and is subject to FINAL DATE INSPECTOR
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 . b D to 0. Pe it
I agree to comply with all city and county ordinances and state laws relating to building y t7'
construction, and hereby authorize representatives -of this city to .enter the above-.
mentioned property for Inspection purposes. Validated by:
Signature of applicant .. Date'' -
Mailing. Address `Validation:
City, State, Zip @\�
r
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBIW%3 FEES
1ST FL. SO. FT. ® $
UNITS
A.C. UNIT
2ND FL. SO. FT.
SLAB GRADE
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. SO. FT.
ROUGH WIRING
DRAINAGE PIPING
WALL SO. FT. ®
ROCK STORAGE
DRINKING FOUNTAIN
SO. FT. ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
HEATING (FINAL)
WATER PIPING
NOTE: Not to be used as property tax valuation
GAS (FINAL)
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
SERVICE
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
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.
SO. FT. ® c
BATH TUB
�/
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/. c
SEWAGE DISPOSAL
FIRE ZONE ROOFING
SO.FT.GAR ® 3/ic
HOUSE SEWER
FIREPLACE
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 APPJEOUIP.
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
� /
w !� �
�/
REMARKS:
/D-
-
7
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION 8
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL