POL (12957)77490 Loma Vista
12957
_ Legal Description
ContractorProject Description poor and Spa-
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Address 3; setback ®k per setback adept
43,:3115 Madison St.
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CiNt io, CA Zip 92201—
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' State Lic.
& Classff.3487
Tel.: 347-595
City
Lic. #js1
Sq. Ft.
Size
1 i`
No.
Stories Units:
• Arch. Engr.; -,-
Designer
.Y.
New ❑ +,Add ❑
-
Alter ❑ Repair ❑ ' 4 Demolition ❑
-'Address.
Tel.
: .¢
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,t City;'
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__7
Zip
State
Lic. #
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44. , _ LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that [ ark licensed under provisions of Chapter 9 (commencing with Section
/000) of Division 3 ifi usiness a d Pr es 'ions Code, and m license is in full force d
effect 7 y an
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SIGNATURE ' DATE
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OWNER•BUILDERDECLARATION
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
i• , permit -to construct, alter, improve, demolish, or repair any structure:, prior to its issuance also
•u 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 thathe is exempt therefrom, and the basis
forrthe alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than live hundred dollars ($500). ,_
•20 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
Estimated Valuation$241000..00
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PERMIT
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Plan Chk� Dep.
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Plan Chk. Bal.
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'Const.
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Mech.
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Electrical -
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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.)
Plumbing
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- ❑ 1, 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
':r 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.). �-
' ❑ I am exempt under Sec. B. 8 P.C. for this reason
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• .S.M.I. • •
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Grading
-.
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Driveway Enc!
Date Owner
Infrastructure
WORKERS' COMPENSATION DECLARATION
t
hereby Virm that I have a certificate of consent to self -insure, or a certificate of
Worker's Co ensation Insurance, or a certified cQ y■thereo .,(Sec. 3800 abQQ'orjjCode.:)
Policy N � Company '.6�a
[I Copy is filed with the city. ❑ Certified copy is hereby furnished.
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TOTAL
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CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
REMARKS
C. `'' '�} p c
l',005 812. � I'}wl aix+"bik�`+'..�.; - va ar7 �e�. 14
This section need not be completed if the
c ( p permit is for one hundred dollars ($100) valuation
Or leI certify
- 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.
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' Date = Owner
NOTICE TO APPLICANT: If, after making , this Certificate of Exemption you -should -become,.
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
ZONE:
"Minimum Setback Distances:
BY:
• S„ ` ' '
Front Setback from Center Line
Rear Setback from Rear Prop. Line' .
coNsrRucnoN 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.)
Lender's Name
FINAL DATE
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Side Setback from Property, Line
'
f INSPECTOR
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.
Issued by:
Validated by:
Date Permit
�
Signature of applicant Date
Mailing Address
Validation: -
i
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES,'
IST FL. SQ. FT. $
UNITS
t
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS u
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCT WORK
ROCKSTORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
DRAINAGE PIPING
CARP. SQ. FT. ®
GAS (FINAL) TEMP. POLE
WALL SO. FT. ®
DRINKING FOUNTAIN
SQ FT ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
GRADING
cu. yd.
$ plus x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
ROOFING�7
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.
SQ. FT. ® c
BATH TUB
SPARK ARRESTOR
SQ. FT. ®c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
LATHING
SQ.FT.GAR ® 3/ac
HOUSE SEWER
MESH
GAS PIPING
PERMIT FEE
INSULATIONISOUND
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 GOND. SOLAR
SETBACK
GROUND PLUMBING y (�1NDERGROUND
(�
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB. BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS u
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. ��/�� j
FRAMING
FINAL INSP.
ROOFING�7
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REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION 2 f
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL