9602-100 (PLBG)
79900 Arnold Palmer #1-F
LICENSED CONTRACTOR DECLARATION
ALC 9 13M] DING PERMIT PERMITi fl r ;
N t j I hereby affirm that I am licensed under provisions of Chapter 9(commencing with DATE VALUATION LOT TRACT
W Section 7000) of Division 3 of the Business and Professionals Code, and my
O Ch 5810% B-I I Il30/97 JOB SITE ADDRESS 79-900 ARNOLD PALt1 ER 014' APN
n 0 License is In full force and effect.
n Wcense# Lic.Class Date-
OWNER CONTRACTOR
Z Date S 6 SignatureofContractor /" TIM CONSTRUCTION WNC
- a: OWNER-BUILDER DECLARATION PCIA WEST RESIDENTIAL ASSOC.R} 77-799 JACKALDR.STT?.')3
J lU 1 hereby affirm that I em exempt from the Contractor's License Law for the 35-940 PGA BLVD. s BERMUDA DUNES CA 9220
following reason: I.A.QUINTA CA 92253 (619)772-3.585 C.RL#
CL
U) ( ) I, as owner of the property, or my employees with wages as their sole (61,9)771-1234
Z compensation,will do the work,and the structure is not Intended or offered for DESIGNER/ENGINEER
3 sale (Sec.7044, Business&Professionals Code). USE OF PERMITI•fY•utVt-x7tivV
-
( ) I, as owner of the property, am exclusively contracting with licensed
,
contractors to construct the project(Sec.7044,Business&Professionals Code).
( ) I am exempt under Section B&P.C.for this reason SEWER CONNtEC!':FOR 0010 COURSE KF-S`('ftC)OM
`Noc
Date Signature of Owner " e aw
Above ited rettttnuor was also the genxmw,cont.for cm.4"Xtiort oft'estfootn.
N I
WORKER'S COMPENSATION DECLARATION ,. FEE DESCRIPTION FEES
4. Q I hereby affirm under penalty of perjury one of the following declarations:
g Z ( ) I have and will maintain a certificate of consent to self-insure for workers'
o CUWRAC,I'ANIOtIN i' 4314100.LS
O compensation, as provided for by Section 3700 of the Labor Code, for the
X W W performance of the work for which this permit is issued.
p J J ( ) I have and will maintain workers'compensation insurance,as required by
CO Q U Section 3700 of the Labor Code,for the performance of the work for which this
p U t permit is issued. My workers'compensation insurance carrier&policy no. we:
a Carrier Policy No.
Z (This sectiohFrS &d'Ii&M completed if the permit valuatiohYi§1&e-$fbb.00 or less). ESTIMATED COST SIE CONST'.R>I MON 430.00
r- ( ) I certify that in the performance of the work for which this permit is issued, PERMIT EEE SUMMARY
I shall not employ any person in any manner so as to become subject to the PT,t)Mi1f 4G E'ER, _SEW R 101000-419-00()
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
J Code, I shall forthwith comply with thoserovisions.
Date: Ab; Applicant co
Warning:Failure to secure.Workers'Compensa4on coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. a( Q
IMPORTANT Application is hereby made to the Director of Building and Safety A
for a permit subject to the conditions and restrictions set forth on his application. 10
1.Each person upon whose behalf this application is made&each person at —-- ,
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to,&shall, indemnify
&hold harmless the City of Indian Wells, its officers,agents and employees. SUB-TOTAL CONSTRUCTION AND PLAN CHECK $30.00
2.Any permit issued as a result of this application becomes null and void if LESS PRC-PAID FEES S0:00
work is not commenced within 180 days from date of issuance of such
permit,or cessation of work for 180 days will subject permit to cancellation. TOTAL PERMIT FEES D VE N01*V* 530.00
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City,and State laws relating to the building f
• Jconstruction,and hereby authorize representatives of this City to enter upon the I IIIIIIIIIIIIIIIIIIII IIII 52
above-mentioned property for inspection purposes. l IE
Signature (Cwner/Agent) ' ' "' Date ;/4/ ' RECEIPT DATE BY DTE INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K to Wrap F.A.U.
Framing Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS _ steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg.Test
Final Gas Piping
PLUMBING. APPROVALS Gas Test
Electric Final
Waste Lines Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final '
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
1
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)
IIIIIIIIIIIIIIIIIIIIIIIII 53
IE A' 1
P.O. BOX 1504 N o, 12714
4
Building 79-900 Arnold Palrmr 78-105 CALLE ESTADO
Address LA QUINTA,CALIFORNIA 92253
Ownersunrise Desert Partners
Mailing BUILDING: TYPE CONST. OCC.GRP.
Address42_50p Cook Street #200
A.P. Number
City Zip Tel.
Palm Desert, qA 92260 1568-2828 Legal Description
Contractor Project Description Replace pool- heater Pool 1F
Trident Pools
4045 Mockingbird Trail
CIndian Wells, 8 32210 T[e1- 1127
State Lic. City
&Classif. 260950 Lic.# 351 Sq. Ft. No. No. Dw.
Arch., Engr., Size Stories Units
Designer New ❑ Add ❑ Alter ❑ Repair❑ Demolition ❑
Address Tel.
City Zip State
Lic.#
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm tf�at I am licensed under provisions of Chapter 9(commencing with Section
10001 of Division 3'ooff the Business and Professions Code,and my license is in full force and
,,effect. _,4 !/fir•. /l.}Z�/( / "Zi, f t4-1
SIGNATURE" C '" a DATE
1`` J OWNER-BUILDER DECLARATION Estimated Valuation1 3t�o
I hereby affirm that I am exempt from the Contractor's License Law for the following 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 permit to file 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 .plan Chk. De
,P-'for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit p
r 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.
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, 30.00
provided that such improvements are not intended or offered for sale. If, however, the building Mech.
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.)
O 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.1.
such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
Grading
❑ I am exempt under Sec. B.&P.C.for this reason
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. 0 Certified copy is hereby furnished.
TOTAL 30.00
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.) ,l
I certify that in the performance of thg workifor 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
Calif(ornia.
Dates Gj
NOTICE TO APPLICANT. If, after making.this ACertificate 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 �� F
Lender's Address
This is a buildingFINAL DATE INSP.ECTOR�`—
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 /I Perini �r•A
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- N (}�
mentioned property for inspection purposes. Validated by: �"' � [/y 4/ Il//
Signature of applicant Date 1,J z;t'g
Mailing Address Validation:
City, State, Zip ` 'o
R
CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES
1ST FL. SO.FT.® $ UNITS
YARD SPKLR SYSTEM
2ND FL. SO.FT.a
POR. SO.FT.® MOBILEHOME SVC. BAR SINK
GAR. SO.FT.® POWER OUTLET ROOF DRAINS
CAR P. SO.FT.® DRAINAGE PIPING
WALL SO.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 LAUNDRYTRAY
i 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. SQ.FT.RESID®1+/.c SEWAGE DISPOSAL
SO.FT.GAR®3/ac HOUSE SEWER
GAS PIPING
PERMIT FEE PERMIT FEE PERMIT FEE
DBL TOTAL FEES MICRO FEE MECH.FEE EPL.CK.FEE CONST.FEE ELECT.FEE SMI FEE PLUMB.FEE
I
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.IEQUIP.
REINF.STEEL GAS(FINAL) TEMP.POLE
GROUT WATER HEATER SERVICE FINAL INSP.
BOND BEAM WATER SYSTEM
GRADING
LUMBER GR. %% FINAL INSP. cu.yd.
FRAMING AL 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
+-- IIIIIIIIIIIIIIIIIIIIIIIII 5444
IE A' /
P.O. BOX 1504 No. 12757
Building 79-900 Arnold Palmer 78-105 CALLE ESTADO
Address LA QUINTA,CALIFORNIA 92253
Owner PGA West Residential Association
BUILDING: TYPE CONST. OCC:GRP.
Mailing
Address P.O. Box 1060
A.P. Number
City Zip Tel.
La Quinta, CA 922.53 1 (610)771-1234 Legal Description
Contractor Project Description Restroom
C & R Western Construction
A Jdyg94 Lennon Place, Suite Al
CityZip Tela
Palm Desert, "A 92269 (619) 346-5527
State Lic. City t
&Classif. 6755733 Lic.# 3 Sq. Ft. 355 No. No. Dw.
Size Stories Units
Arch., Engr., D
Designer • • Adolph New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
A,y e=105 riviera T11619)771-0577
City Zip State
La Quinta, CA 92253 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. .r? •0, r
SIGNATU/RE_' •C ' !• DATE ,
OWNER-BUILDER DECLARATION Estimated Valuation OQO ()()
I hereby affirm that I am exempt from the Contractor's License Law for the following •
reason: (Sec. 7031.5,Susiness 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 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 permit Plan Chk. Dep.
subjects the applicant to a civil penalty of not more than five hundred dollars($500). Plan Chk. Bal. 1 •d
O 1,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 Const. 25.00
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.)
❑ I,as owner'of the property,am exclusively contracting with licensed contractors to con- Plumbing 27.00
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law C
does not'apply to an owner of property who builds or improves thereon, and who contracts for .S.M.I. .5J' 0'
such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
Grading
O 1 am exempt under Sec. B.&P.C.for this reason
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
0 Copy is filed with the city. ❑Certified copy is hereby furnished.
TOTAL `3• YS
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 lhg 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: It, alter making this Certificate of Exemption you should become ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith MIr11fT1Um 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 PFOpl3rty`I_lne— l! _-
Lender's Name
Lender's Address FINAL DATE Ijfl INS EP CTOR
This is a building permit when properly filled out,signed and validated,and is subject to vl
expiration it work thereunder is suspended for 180 days. J IIJ'
I certify that I have read this application and state that the above information is correct. Issued by: 1II1pate F170 n -t Pegi,t
I agree to comply with all city and county ordinances and state laws relating to.buildingC 11 yy
construction, and hereby authorize representatives -of this city to enter the above-.
mentioned property for inspection purposes. Validated by:
Y p `
Signature of applicant -Date-
Mailing
ate Mailing Address 'Validation: ffff a _•
City, State, Zip
CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES
IST FL. SQ.FT.® $ UNITS
2ND FL. SQ.FT.@
YARD SPKLR SYSTEM
POR. SQ.FT.® MOBILEHOME SVC. BAR SINK
GAR. SO.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 lax 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. TEMP USE PERMIT SVC WATER CLOSET'
COMPRESSOR HP POLE,TEM/PERM LAVATORY
HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER
BOILER B.T.U. SQ.FT.®c BATH TUB
SO.FT.®c WATER HEATER
MAX.HEATER OUTPUT,B.T.U. SQ.FT.RESID®1+/4 c SEWAGE DISPOSAL
SO.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 APPJEQUIP.
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
IJ IIIIIIIIIIIIIIIIIIIIIIIII 55 ..
IE 44
P.O. BOX 1504
No.
Building AMLD PAY78-105 CALLE ESTADO
,<SEft
Address 79-9Qtf LA QUINTA,CALIFORNIA 92253
Owner _
fItTST" BUILDING:-TYPE CONST. OCC:GRP.
Mailing
Address 75--05 CSSMY CLU'L DA
A.P. Number
City ZipTel.
PAIA DESMT 92260 558-2823 Legal Description
ContractorProject Description PW`L &.SPA' MAMA 16-1'k
G & a POOLS
Address -
P.O„ BOX. 399
City Zip Tela...
CA's' =AL CITY ' 92234 328-2584
State Lic. City
&Classif. .`715796 Lic.# 69 Sq. Ft. No. No. Dw.
. .
Size Stories Units
Arch., Engr.
Designer New LEX Add ❑ Alter ❑ Repair❑ Demolition ❑
Address Tel.
City Zip State
Lic:#
LICENSED CONTRACTOR'S DECLARATION r
I hereby affirm that-f am licensed under provisions of Chapter„9(commencing with Section' ++'
7000)of Division 3 of the Business and Professions Code,and-iny license is in full force and
effect. • r ' v" -^^• ,.7.1c k `i
SIGNATURE.f" DATE
OWNER-BUILDER DECLARATION Estimated Valuation I hereby affirm that I am exempt from the Contractor's License Law for the following 206*=
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 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,of that.he is exempt therefrom, and the basis -
for the alleged exemption. Any violation of Section 7031.5 by'any applicant for a permit 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. 95.22
do the work,and the structure is not intended or offered for sale.(Sec. 7044,Buisness and Const. ' I4fi S 3
Professions Code: The Contractor's License Law does not apply to an owner of property who •
i
builds or improves thereon and who does such work himself or through his own employees, Mech. ,ii7
..provided that'such Improvements are not intended,or offered for sale. If_however„the building
00
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.)
❑ I,as owner of the property,am exclusively contracting with licensed contractors to con- Plumbing 14.00
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law _. 9
does not apply to an owner of property who builds or improves thereon, and who contracts for - S M.1. ' 1♦44
such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) -
Grading
❑I am exempt under Sec. B.8 P.C.for this reason
Driveway Enc.
Date owner Infrastructure
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self•in'sure, 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
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.) - •. ._ t )
I certify that in the performance of the work for which this permit is issued,I shall not , ,y ij1 [ Q7'a ' l.,•
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
cofvsTRucrloN 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
Lenders 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. 0 I
I certify that 1 have read this application and state that'the above information is correct. ISSued*by:y Date 7s 23187 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-
Mailing
ateMailing Address Validation:
City, State, Zip
HARD COPY
CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES
1ST FL. SQ.FT.® $ UNITS
2ND FL. � SO.FT.
YARD SPKLR SYSTEM
POR. SO.FT.® MOBILEHOME SVC. BAR SINK a
GAR. SQ.FT.® POWER OUTLET ROOF DRAINS
CAR P. SQ.FT.
DRAINAGE PIPING
WALL SO.FT.p
DRINKING FOUNTAIN
SO.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 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
SQ.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
I
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 APPJEQUIP.
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