002760 (ELEC)79670 Arnold Palmer
i
IIIIIIIIIIIIIIIIIIIIIIIII 61
IE A'
P.O. BOX 1504 No. 002760
Building 7 7Q ld P-1 LA QUINA CALIFORNIA92253
Address '
Owner
BUILDING: TYPE CONST. OCC:GRP.
Mailing -
Address 75-05 fbantr 7 Mme Dr: A_.P. Number
City Zip Tel.
I Legal Description
Contractor - TQ, PWE f
_ Project Description ..
Address
sam
'City , Zip Tel
State Lic. City
&Classif. : 3D Lic.# Sq. Ft. No. No. Dw.
Arch:,Engr.; Size. Stories Units
-' - ,
Designer j New.3A Add ❑ Alter ❑. Repair ❑ Demolition ❑
Address Tel.
City Zip State
_. Lic.#
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thatI am licensed under provisions of'Chapler 9(commencing with Section.
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
_X f r
effect. . .-k. t-4 tn.'i•, /_r// t
SIGNATURE(\ f •f 4 DATE
OWNER-BUILDER DECLARATION Estimated Valuation
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
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant'for such permit to file a signed statement that he'ts licensed pursuant to PERMIT - AMOUNT
the provisions o/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
/or the alleged exemption. Any violation of Section 7031.5 by'any y applicant•for a permit Plan•Chk. Dep.
subjects the applicant to a civil'penalty of not more than five hundred dollars($500).' Plan Chk. Bal.
0 I,as owner of the property,or my employees with wages as their sole•compensation,will
do the work,and thestructure is not intended or offered for sale.(Sec. 7044,Bussness and Const.
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.)
0 I,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 o/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
❑ 1 am exempt under Sec. B.&P.C.for this reason
Driveway Enc.
Date Owner Infrastructure
WORKERS'COMPENSATION DECLARATION
I'heretiy 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....❑Certified copy is hereby furnished.
TOTAL 22.59
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:)'
I certify that in the performance of thg work for which this permit is issued,I shall not '
=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. * q
I certify that I have read this application and state that the above information is correct. Issued.by: Date .L2"'J." ermlt
I agree to comply with all city'and county ordinances and state laws ielating to building
construction, and hereby authorize representatives',of this,city to-enter the above-.
mentioned property for inspection purposes& f +` (r Validated.by:
Signature of applicant N /T !f«_.l .r1 ! > Date
Mailing Address _ Validation:
City, State, Zip
A6918 12 15 2250 Ck
HARD COPY
CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES
IST FL. SQ.FT.® $ UNITS
2ND FL. SO.FT.
YARD SPKLR SYSTEM
POR. SQ.FT.® MOBILEHOME SVC. BAR SINK
GAR. SQ_FT,® POWER OUTLET ROOF DRAINS
CAR P. SQ.FT.® '
DRAINAGE PIPING
WALL SQ.FT.
DRINKING FOUNTAIN
SQ.FT.® URINAL
ESTIMATED CONSTRUCTION VALUATION $ WATER PIPING
NOTE:Not to be used as property tax valuation FLOOR DRAIN
MECHANICAL FEES WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH)
APPLIANCE DRYER GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY
AIR HANDLING UNIT CFM KITCHEN SINK
ABSORPTION SYSTEM. B.T.U. I 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.RESID®11/4 c SEWAGE DISPOSAL
SQ.FT.GAR®3/ac HOUSE SEWER
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
LUMBER GR. FINAL INSP.
cu.yd.
FRAMING FINAL INSP. $ plus x$ _$
ROOFING REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS,
GARDEN WALL FINAL