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PAT (0108-074) + RPL (14680) + SFD (14014)78830 Lowe Dr 0108-074 14680 14014 LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby,affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) 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, Business & Professionals Code). ( ) I, as owner of the property, am exclusively contacting with licensed contractors to construct the project (Sec. 7044,usingss & Professionals Code). I F () el''am exempt under Section B&P.C. for this reason Q to 9 •• f i Signature of Owner I AT ,•{ w DECLARATION WORKER'S COMPENSATION DEC r I hereby affirm under penalty of perjury one of the following declarations: ( ) I have and will maintain a certificate of consent to self -insure for workers' compensatiori, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ( ) I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier Policy No. (This section need not be completed if the permit valuation is for $100.00 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 sp as to become subject to the workers' compensation laws of California,,' and# agre4 that if I should become subject to the workers' compensation pAovisions of !Section 3700 of the Labor Co6e, I shall forthwith comply with those prove;ions. gate:' T F, ' `` Applicant r rf Warning: Failure to secure Work ersllCompensatio coverage is unlawful and shall subject an employer to criminaVpenalties 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'sfees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 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 applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if 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. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, do State laws relating to the building construction, and hereby authcl z repre ntatives of this City to enter upon the above-mentioned property.br ins((pectibn purposes.11 / ' ,ynature (Owner/Agent) f t ' Date a BUILDING PERMIT PERMIT# t. DATE VALUATION LOT TRACT JOB SITE APN ADDRESS 78 yy{} p Ay,Iy gyp} +Ij pVE OWNER CONTRACTOR / DESIGNER / EN (NEER 7S-830 1-110WERDJUVE LA QiIDUA Cg's 9;7153 rg9l♦ q. USE OF PERMIT 14''.rJ 409 3. F. 'LA7"TIC..0 PA110 w;OVIMP, PER, AkpP CYN')r'D PIM Cl" STAiW4RD PORC:HNATIO 400,00 SN' E917 IN111011 J C011S ' (l), CO NSTRUC;'ITON, HAN 01FIC K ns 101-000.419-318 S52.6s CX%1q aTRUCT;iOTf C 101 ••000-419-000 $i£i.Orr z omt .- ``' ' :. -.1-000 $.: ;3 FAU-69 Cir, 8;1.T$-TO`C.At:.F"ti1.3';w» .t i:CTONAND PL t`;1'X`i7., N TOTAL PFIRMUFU HOW RECEIPT DATE BY DATE FINALED INSPECTOR i rRf.i iis INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs _ j Forms & Footings ` - Underground Ducts 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 BLOCKWALL APPROVALS POOLS -SPAS 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 Final LlEtty Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: RAFTER SIZE AND SPACING SPECIFY ROOFING AND SHEATHING OR OPEN LATTICE I 9( tI (SEE ROOFING NOTE ON REVERSE) ROOF PITCH C7 NOTE: OPEN LATTICE PATIO COVERS MAY BE ATTACHED TO EXISTING FASCIA VIA ONE 1/4" x S' LAG SCREW THROUGH FASCIA INTO EACH RAFTER TAIL. 1/0" .. S" 1 Ar Cron— .— ter, 1-1 .r . - NAIL RAFTER TO BLOCKING 12 BELOW GRADE E Ly PROVIDE1" CLEARANCE o v) d e c -_ BETWEEN POST AND CONCRETE U -STRAP OR ANGLE aH_ NON -CORROSIVE PLATE (4)- 16d NAILS OR BOLT U -STRAP OR ANGLE (4)- 16d NAILS OR BOLT PROVIDE 1" CLEARANCE BETWEEN POST AND CONCRETE BUILDING DEPART Tjf, II III WILL BE CHARGED IF THE APPROVED PLANS AND JOB CARD ARE NOT ON ANCHOR BOLT (EMBED 7' MIN. INTO CONCRETE) THE SITE FOR A SCHEDULED INSPECIIA TYPICAL PATIO COVER CITY OF LA QUINTS CEPTIONS! DATE OF APPLICATION BUILDING & SAFETY DEPT. OWNER'S NAME K J# Ar P R OV E D STREET ADDRESS Q FOR CONSTRUCTION CITY, ST ZIP , 4 L TELEPHONE DATE DATE U v H.O.A. APPROVAL CONTINUOUS LEDGER (SAME SIZE AS RAFTERS) HEADEIZE J l ( 'T' AND 'l' STRAPS 6"x6"x1"xl/8" WITH — —__ RAFTER SPAN: --- ! =- -- 2 ---- O. H. z ` I J z ` _ w O. H. O a ` (4) 16d NAILS OR BOLT POST SPACING:_Ll I z w J U z ' OVERALL LENGTH: ___ -_ --— -- OVERALL LENGTH:__ ___ ev POST SIZE: L_X l (4"x4" MIN.) (0 REAR SETBACK SIDE SETBACK / I 2000 P.S.I CONCRETE —moi ;FINISH GRADE FINISH GRAD L_ J I I"— MIN. 12" x 17' FOOTING I I L J NOTE: OPEN LATTICE PATIO COVERS MAY BE ATTACHED TO EXISTING FASCIA VIA ONE 1/4" x S' LAG SCREW THROUGH FASCIA INTO EACH RAFTER TAIL. 1/0" .. S" 1 Ar Cron— .— ter, 1-1 .r . - NAIL RAFTER TO BLOCKING 12 BELOW GRADE E Ly PROVIDE1" CLEARANCE o v) d e c -_ BETWEEN POST AND CONCRETE U -STRAP OR ANGLE aH_ NON -CORROSIVE PLATE (4)- 16d NAILS OR BOLT U -STRAP OR ANGLE (4)- 16d NAILS OR BOLT PROVIDE 1" CLEARANCE BETWEEN POST AND CONCRETE BUILDING DEPART Tjf, II III WILL BE CHARGED IF THE APPROVED PLANS AND JOB CARD ARE NOT ON ANCHOR BOLT (EMBED 7' MIN. INTO CONCRETE) THE SITE FOR A SCHEDULED INSPECIIA TYPICAL PATIO COVER CITY OF LA QUINTS CEPTIONS! DATE OF APPLICATION BUILDING & SAFETY DEPT. OWNER'S NAME K J# Ar P R OV E D STREET ADDRESS Q FOR CONSTRUCTION CITY, ST ZIP , 4 L TELEPHONE DATE DATE U v H.O.A. APPROVAL OWNER/BUILDER INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by law' to put their license number on all permits for which they apply. i If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the State and Federal Government as an employer -and you are subject to several obligations including State and Federal income tax withholding, federal social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to worker's compensation insurance. For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N. Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampi La Qui , CA 922 3 (760) 7 -7012 FAX: ( 0) 777-7 1 'S SIGdNAIVJRE/DATE PROPERTY d2 4 - PERMIT NUMBER(s) SKETCH ADDENDUM Case No CONVENTIONAL Fite No 107012JA Property Address 78830 LOWE DR _ _ ^_ City LA QUINTA County RIVERSIDE State CA _Zip 92253 __ Borrower JANOSIK Lender/Client COUNTRYWIDE FUNDING Appraiser Name ROB KELLEY I Comments '/C Address 2500 E. IMPERIAL HWY, BREA, CA 92821 3.0' N .. $ 13.0' 6.0' rL. 'AT -.IONS. SUMMARY.. Code _; ;Desch on';: ': ; :: Size. Totals P _ GL711 First Floor 1406.00 1406.00 GAR Garago 484.00 484.00 1 t J .S-4 0 N N 2 Car Garage a r4 N ........... cr Scale: 1=15 17.0' LIVING: AREA BREAKDOWN _ Breakdown Subtotals Master First Floor Bedroor 10.0 20.00 2.0 x 6.0 12.00 Master 0.5 x 2.0 x 2.0 Bath O 0.5 x 2.0 x 2.0 2.00 N M 11.0 x I Comments '/C Address 2500 E. IMPERIAL HWY, BREA, CA 92821 3.0' N .. $ 13.0' 6.0' rL. 'AT -.IONS. SUMMARY.. Code _; ;Desch on';: ': ; :: Size. Totals P _ GL711 First Floor 1406.00 1406.00 GAR Garago 484.00 484.00 1 t J .S-4 0 N N 2 Car Garage a r4 N ........... Scale: 1=15 LIVING: AREA BREAKDOWN _ Breakdown Subtotals First Floor 2.0 x 10.0 20.00 2.0 x 6.0 12.00 0.5 x 2.0 x 2.0 2.00 0.5 x 2.0 x 2.0 2.00 11.0 x 35.0 595.00 23.0 x 26.o 598.00 5.0 x 9.0 45.00 i P.O. BOX 1504 Building 78-830 Lowe Dr. LA OU NTA, CALIFORNIA 92253 Address Owner Richard E3einko Mailing Safi© BUILDING: TYPE CONST._ Address A.P. Number CityZip Tel. La . Quinta r 'CA 12253 1 Legal Description Ra«o Pools AV jress156 Boaton C* . CNdio, CA Zip 92201 Tel 347a-3627 State Lic. C53 573948 City 2635 & Classif. Lic. # Arch:, Engr., Designer Address Tel. CityI Zip I State C. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 000) of Division 3 of the Business and<Professions Code, and my license is in full force and ffect. S. IGNATURE DATE OWNER -BUILDER DECLARATION 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, after, 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 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 subjects the applicant to a civil penalty 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 improve for the purpose of sale.) ❑ 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 does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) (fcensed pursuant to the Contractor's License Law.) ❑ 1 am exempt under Sec. B. & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION 1 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. ❑ Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATIONINSURANCE (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 aws of California f, y / Date +Owner 't rf NOTICE TO APPLICANT: ff, 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. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND 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, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. This is a building permit when properly filled out, signed and validated, and is subject to expiration if work thereunder is suspended for 160 days. 1 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 ateMailing Address City, State, Zip Project Description No. 14680 OCC. GRP. Pool and Spa Sq. Ft. No. No. Dw. Size . Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation $13,000.00 PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. 93.60 Const. 144.00 Mech. 24.00 Electrical 45.00 Plumbing 27.00 S.M.I. Grading Driveway Enc. Infrastructure TOTAL 333.60 REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by: Date - Perit, Validated by: Validation: FEB 0 3 1 Lr CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBIW FEES e 1ST FL. SO. FT. @ $ 2ND FL. SO. FT. POR. SO. FT. @ GAR. SO. FT. @ CAR P. SO. FT. WALL SO. FT. SO. FT. @ ESTIMATED CONSTRUCTION VALUATION $ UNITS MOBILEHOME SVC. POWER OUTLET YARD SPKLR SYSTEM BAR SINK ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING NOTE: Not to be used as property tax valuation BONDING FLOOR DRAIN MECHANICAL FEES FORMS WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GAS (ROUGH) GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED OTHER APP.IEOUIP. LAUNDRY TRAY AIR HANDLING UNIT CFM TEMP. POLE 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 @ 1 Va c SEWAGE DISPOSAL REMARKS: SO.FT.GAR @ V4c HOUSE SEWER GAS PIPING PERMIT FEE MIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE EPL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB.FEE STRUCTURE PLUMBING ELECTRICAL .0 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 N ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APP.IEOUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM FINAL INSP. vgrD GRADING -cu. yd. II $ plus x$ =$ LUMBER GR. FRAMING FINAL INSP. ROOFING l /L > r J ?J -5 / Z/ ! ////%%L S' REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTIONOft4 Y, CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES11NITIALS GARDEN WALL FINAL contractor 14z Zo rda S owner J \ J ? 0 Address Job Address This form shall be posted on the job with the Building Inspection Card at all times in conspicuous place. It is the responsibility of the General Contractor or the Owner/Builds to monitor the sub -contractors that are on this list are the same persons performing t] work. Any changes of this list must be approved by the City of La Quinta Department < Building and Safety prior to work being performed by a changed sub -contractor. Failure i comply will result in a stoppage of work and/or the voidance of building permit. TRADE SUB -CONTRACTOR NAME CONTRACTOR'S LICENSE NO. WORKMAN COMP. NO. ON FILE CITY BUSINESS LICENSE NO. GRADE/ EXCAVATE H 3 r l Nw PIPELINES CEMENT/ FOUNDATIONS CEMENT/WALKS & DRIVES ASPHALT FRAMING STEEL/ STRUCTURAL MASONRY PLUMBING D LATHING DRYWALL PLASTERING HVAC ELECTRICAL ROOFING SHEET METAL FLOORS GLASS/ GLAZING INSULATION SEWAGE DISP PAINTING/ DECORATING TILE CABINETS/ INSTALLATION ORNAMENTAL METAL FENCES/ BLOCK WALLS LANDSCAPING OTHERS `44 ` ? M % u P.O. BOX 1504 Building 78-105 CALLE ESTADO Address 78-834 Lowe DRive LA QUINTA, CALIFORNIA 92253 No. 14014 Owner AcaciaConstructionMailing BUILDING: -TYPE CONST. VN OCC: GRP. A.P.=Number 604-232-032 _ Legal Description Lot 161 Tract 23260 Project Description SVD Plan A R3 Phase •3 _ Address 8141 E. Kaiser Blvd. #310 City Anaheim ZipTel. 92808 71+4-282-51800 Contractor Same- ACaCia ., Address City Zip Tela State Lic. City & Classif. 293954 Lic. # 1612 Sq. Ft. 1400 No. No. Size Stories Units Dw. -• Arch.; Engr.; - - - - - - Designer DC Desion New IX Add ❑ Alter ❑ Repair ❑ -- Demolition ❑ 2d0e35T 1 Irvine Ave. 714-641-1505 CityZip Santa Ana Heig is 92707 State Lic. # LICENSED CONTRACTOR'S DECLARATION ` I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 4 00) of Divisjion 3 of the Business and Professions Code, and my license is in full force and. SIGNATURE - DATE OWNER•13UILDER DECLARATION I hereby affirm that 1 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 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 basts for the 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 five 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 improve for the purpose of sale.) Estimated Valuation $84840.00 PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal• A C 486 . 56 Const. 572.00 Mech. AA 47. ea u'Q Electrical 30 t Plumbing • • • . 00 0 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 does not apply to an owner of property who builds or improves thereon, and who contracts for projects with a contractor(s) licensed pursuant to the Contractor's License Law.) - O I am exempt under Sec. B. 8 P.C. for this reason S. M. 1. g 48such Grading 20.00 -Driveway Enc. - Date owner Infrastructure 1948.90 WORKERS' COMPENSATION DECLARATION I herepy affirm that I have a certificate of consent to self -insure, or a certificate of Worker's,oeompensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) . Polis o. Company LT'Copy is filed with the city. ❑ Certified copy is hereby furnished. TOTAL 3306.24 CERTIFICATE OF EXEMPTION FROM 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 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: BY: Minimum Setback Distances: 4 Front Setback from Center L Rear Setback from Rear Prop. 1=4 CONSTRUCTION LENDING AGENCY 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 Side Street Setback from Center Side Setback from Property Line FINAL DATE INSPECTOR Line 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: Date ' Permit Validated by: Signature of applicant Date Mailing Address Validation: City, State, Zip CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES IST FL. SO. FT. ® $ UNITS A.C. UNIT COLL. AREA SLAB GRADE 2ND FL. SQ. FT. YARD SPKLR SYSTEM HEATING (ROUGH) MOBILEHOME SVC. BAR SINK POR. SQ. FT. ® SEWER OR SE T GAR. SQ. FT. ® POWER OUTLET ROOF DRAINS FOUND. REINF. DRAINAGE PIPING CAR P. I SQ. FT. METER LOOP HEATING (FINAL) WALL SQ. FT. REINF. STEEL DRINKING FOUNTAIN SQ FT ® URINAL ESTIMATED CONSTRUCTION VALUATION $ WATER PIPING NOTE: Not to be used as property tax valuation WATER HEATER FLOOR DRAIN MECHANICAL FEES FINAL INSP. WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER FINAL INSP. Z) GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LUMBER GR. LAUNDRY TRAY AIR HANDLING UNIT CFM FINAL INSP. 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+/e c SEWAGE DISPOSAL SQ.FT.GAR ® 3/ac HOUSE SEWER GAR. FIREWALL GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE TOTAL FEES MICRO FEE --JDBL MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR A SETBACK GROUND PLUMBING UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SE T ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) l D METER LOOP HEATING (FINAL) OTHER APPJEQUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM FINAL INSP. Z) GRADING CU. yd. $ plus x$ =$ LUMBER GR. FRAMING FINAL INSP. ROOFING / - REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL ING I MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL