BLCK (11773)77490 Loma Vista
11773
La Qui92253 to ,1 CA;- 92253 _ _770-0710
contractor,.,,,-,
.� bristruction Dic
Address '
57--370..29-Palms Fizzy. 0201
City Zip Tel
Yidcca 92284 365-8691,
State Lic. City
& Classif. '; . 435033 Lic. # 2533
_ Arch. Engr:-.�'
Designer
Address .?E:�: Tel. y
• i
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
Legal Description
Project Description 175 tt of 71 high block wa-1.1
I. " - • ...
Sq. Ft. No.
Size Stories
' I New ❑ Add ❑ Alter ❑
City r•t.
Zip
State
Lic. #'
r
' LICENSED CONTRACTOR'S DECLARATION
,hereby affirm that�I. am"-Ilc—med de'iprovisions of Chapter 9 (commencing with Section
7000) of DDivision 3 of the Business and Professions Code, and my license is in full force and
effect 7 _
_SIGNATURE i DATE
-
1 OWNER -BUILDER DECLARATION
'
I hereby affirm that -1 am exempt from the Contractor's License Law for the following
reason: -(Sec. 7031.5,Business and Professions Code: Any city orlcounty which'•requires a
permit to construct,'alter, improve, demolish, or repair any structure, I prior to •its issuance also
Estimated Valuation
requires the applicant.for such permit to file 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 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section- 703,1.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (S500).
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
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 improve for the purpose of sale.)
_
PERMIT
Plan Chk. Dep. '
-
Plan Chk. Bal.
Const.
Mech. -
Electrical
Plumbing
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project'.(Sec.7044, Business and Professions Code: The Contractor's License Law
S. M. 1.
does not apply to an owner of property who builds or improves thereon, and who contracts for
- - such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) - -- -
�' '
❑ 1 am exempt under Sec. B. & P.C. for this reason
Grading
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.)
Poky No. Company
Copy is filed with the city. , ❑ Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM
s
No. Dw.
Units
Repair ❑ Demolition �❑
,r
,375400
AMOUNT
--72;. 00
s
.5o
a . WORKERS' COMPENSATION INSURANCE REMARKS
(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
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 Setb L; -f C t L'
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
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.
I certify that I have read this application and state that the above information is correct.
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.
Signature of applicant Date
Mailing Address
City, State, Zip
a. rom en er Ine
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by: ,
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
ROUGH WIRING
DUCT WORK
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (ROUGH)
DRAINAGE PIPING
CAR P. I SQ. FT. ®
I
REINF. STEEL
WALL SQ. FT.
GAS (FINAL)
DRINKING FOUNTAIN.
SQ FT ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER HEATER
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL 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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1+/a c
SEWAGE DISPOSAL
SQ.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
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
ROCKSTORAGE
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
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION 7 �/ '3
V
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL