SFD (0012-060)51620 Avenida Madero
0012-060
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 xp. Date
Date # :rd Signature of Contractor
OWNER -BUILDER DECLARATIONY/
I hereby affirm under penalty of perjury that'1 am exempt from the COntfaCtOr S
License Law for the following reason: °/ ✓(
( ) I, as owner of the property, or myemployees 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).
( ) 1, 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
Date . Signature of Owner
WORKER'S COMPENSATION DECLARATION
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'
compensation, 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.
STATE YOND 2W 994:0967J
(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 so as to become subject to the
workers' compensation laws of California, and agrQe that if I should become
subject to the workers' compensationpp,rovisionsi,9t Section 3700 of the Labor
comply Code, I shall forthwith com I wit, t)i
sstprovisio s- '
Date:f' 'Z'0'-"Y'0` Applicant—
Warning:
pplicant Warning: Failure to secure WorkersCompensation coverage is"
f un- d
shall subject an employer to criminal penalties and civil fines up:tb $100,000, in
addition to:the cost of compensation, damages as provideedrf& in Section 3706
of the Labor Code, interest 66;d attorney's fees. i
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, and State laws relating to the building
construction, and hereby authorizefrepre ntatives of this City to enter upon
the above-mentioned pr rty for In` e 2.pWose%
h""".9.. ti.•,r /•
Signature (Owner/Agent) Date % ' co
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (XJJ,,,t TRACT
j 2 ..
1 + .,.. iS !/ .!.ice..- • hF4 C! 6 { ..% e; WX7.5 P .
JOB ,SITE °
APN
ADDRESS
OWNER
CONTRACTOR /DESIGNER / EN INEER
LEN DEL IVEN f.'O A 1. &ITIM
mqy.Jl. , v.f`:.L4 d'oXGf=. , .iJ. ".
PO BOX 450
51-37 0 AVIDAIDA BERM AS, RI?'x'O 2, F°JA
I..A QLiINTA. CIA 92253
Lai. QC3TINTA. CA 9225
CRUO 859
USE OF PERMIT
b -
.S'i'?O ITfa,'1.0 DEBLOC K W,ALIL P0011 &. SPA, OR
l::-11bIi'1!:WAY.I PPRO..ACI'I'>
TRACT CONSTRUCTION 11360.100 S
Pt IR.CWP.,PsM 22.00 STS'
I F . WOOD IFFI1C,F 110.00 111
O S CS SR:S, 00 SP
MDMA' IU CC) .Kr OF CC)Rt ” 1Z'Ri"ON
M083A)
EFONPI`TRU("'TION C`B2 101,-000.4113-(103 `1541.00
PLA.W €"d-tiXg, F ER 101-000-439-318 '4a ng
i ME DEPt„ ;SIT 101-000-439-318 4211101110
% 'f '.L HA !>it"AL 1PFX 101 -OW -421-000 45.50
R L Z CT R) Vo A1, ITI? 1,01.000.4.20,-000 $1011,21
PP.,UMBI'No FEE 9--000 VC4.\75
4'a'12ts' t1 ib101'ICAi I+I+: • iZ, iD 3014=441-000 $8.61
;
113RA 1.iAFOFE-9 101,000•423-000 MOD
I:sZVi:Wl ER I M P.t'f,C T FEE $1,067.00
P'R%CIS%PIAN 101-000-441-345 $100.00
SUB-`:i'E1`1.:AL C<,%WST.i:213't `"F:j ON' AND PLM C'MOR
$3;:366:35
MMS PRE -PAID 1W3
4250-00
TC)TAL IMFMIT MS DUE NO, IN
RECEIPT
DATE /
BY
DATE FINALED
INSPECTOR
IGS tom. /J ;D
'r
roto
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
_!
nc
`
Underground Ducts
Forms & Footings
.Y
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
`
STT
F.A.U.
Framing..
pC
Compressor
Insulation
p _ p
sem"
Vents
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Laths"b
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
_ _ _ _/
1
Heater Final
I Water Piping
(
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
7
Encapsulation
I Gas Piping
Gas Test
't?7— t5-ot
S-7
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
/. _q zrp
7'
Underground Conduit
Rough Wiring
j Low Voltage Wiring
Fixtures
Main Service
I Sub Panels
G.F.I.
Detectors
Use of Power
Utility Notice (Pe
Building
Address
Owner/
T4tyl 4 4 "
P.O. BOX 1504
78-495 CALLE TAMPICO
V/.J, C f LA QUINTA, CALIFORNIA 92253
Mailing
Address
r City + Zip Tel. / ,
CityIZ • Li ta
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.
SIGNATURE 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
permil 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
theprovisions 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 five hundred dollars ($500).
17 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
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 1 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
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.)
I 7 I am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
Ihereby 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
f7 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it 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., It, 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.
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
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.
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 a0plicant Date
Mailing Address
City, State, Zip
APPLICATION ONLY
BUILDING: TYPE'CONST. OCC. GR r
A.P. Number 6"fl
Legal Description YZ.Grw-r, ''L '
-
Project Description ` 4 ryw)K.-Y
Sq. Ft. NO. No. Dw.
Size Stories Units
Add ❑ Alter ❑ Repair ❑ Demolition ❑
imated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
0 100 I AMOUNT
REMARKS r
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 Permit
Validated 1
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Addre s
`City
Zip
Tel
State Lic.
& Classif. fJ L '
City
Lic. # 4e t;
Arch., Engr.,
Designer C/_{
Address
Tel.
CityIZ • Li ta
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.
SIGNATURE 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
permil 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
theprovisions 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 five hundred dollars ($500).
17 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
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 1 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
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.)
I 7 I am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
Ihereby 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
f7 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it 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., It, 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.
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
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.
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 a0plicant Date
Mailing Address
City, State, Zip
APPLICATION ONLY
BUILDING: TYPE'CONST. OCC. GR r
A.P. Number 6"fl
Legal Description YZ.Grw-r, ''L '
-
Project Description ` 4 ryw)K.-Y
Sq. Ft. NO. No. Dw.
Size Stories Units
Add ❑ Alter ❑ Repair ❑ Demolition ❑
imated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
0 100 I AMOUNT
REMARKS r
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 Permit
Validated 1
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 12/28/00
No. 21426
Owner NameLendel Ventures
No. 51-620 Street Avenida Madero
City La Quinta
Tract # BLK25U2 Lot # 7
Type of Development Single Family Residence
Comments
APN # 773-113-001
Jurisdiction La Quinta
Permit # 0012-060
Log #
Zip 92253 Study Area
Square Footage 1366
No. of Units 1
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It
has been determined the above-named owner is exempt from paying school fees at this time due to the following reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
2.05 X 1,366 or $ 2,800.30 the property listed above and that building•
permits and/or Certificates of Occupancy for this square footage in this proposed project may nmvi be issued
Fees Paid By CC / Valley Independent Bank - Mr. Lench Telephone ?60-564-1866
Name on the check ;
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Annette Barlow
JNSignature
Payment Received $2,800.30
Check No. 235125
401ICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
:ollect them on the District('s)(s') behalf, whichever is earlier. -
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
k
c0,d M NAun ia t fl TITLE ca.
RECORDIT!G REQUESTED BY:
CHICAGO TITLE COMPANY COMPANY
10i98KC 2070570
WHEN RECORDED MAIL THIS DEED AND,
UNLESS OTHERWISE SHOWN BELOW,
MAIL TAX STATEMENTS TO:
LENDEL VENTURES, INC.
P.O. BOX 450
LA QUINTA, CA 92253
T,Q4 0a00%7
DOC p 2000-328367
08/22/2000 08:00A Fee:19.00
Pape 1 of 2 Doc T Tax Paid
Recorded in Official Records
County of Riverside
Gary L. Orso
Assessor, County Clerk & Recorder
NI I I
I A I R I L
CrRANT DEED
I
• _ COPY - LONG 001FUND NCHG EXAM
The undersigned grantor(s) declare(:):
A&D
Documentary transfer tax is 516.50. AG
(XXX) Computed on full value of property conveyed, or
( ) Computed on full value less liens and encumbrances remaining at time of sale.
( ) Unincorporated area: City of J_A Qi -j i mTft and
FORA VALUABLE CONSIDERATION,. receipt. of which is hereby acknowledged,
FRITZ B. BURNS FOUNDATION, A NEVADA NDN -STOCK, NON' -PROFIT CHARITABLE COR RATION
hereby GRANT(S) to
1
/y LENDEL VENTURES, INC., A CALIFORNIA CORPORATION
(" )
the real property in the City of LA QUINTA, County of Riverside, State of California,
described as:
The North 1/2 of Lot 7 in Block 25, Unit No. 2, of. Santa Carmelita ay Vale
La Quinta, as per map recorded in Boo:c 18, Pages 55-56.of:Maps, records of
Riverside County
Dated August 3, 2000
State of California FRITZ B. BURNS FOUNDATION
County of LDS A NCS t L C S } S.S. A NEVADA NON -STOCK, .NON= PROFIT
OnAUS SOU O CHARITABLE CORPORATION
before me, L,3. Q.RWL_! NSori Naim
1 U b [ C. , personally appeared BY
— LcL.Seph E. Rawl inson and T:orraine''F_ Perry J09EPHvE. RAWLINSON, TITLE pgESIDENT
I ;
personally known to me (or proved to me 'on
the basis of satisfactory evidence) to be
the person(s) whose name(s) is/are subscribed RRAINE F_ PERRY, ASSISTA T SECRETARY
to the within instrument and acknowledged to'
me that he/she/they executed the same in ah a`
his/her/their- authorized capacity(ies), and RAWUNSM.
that by his/her/their signature(s) on the
instrument the person(s), or the entity upon OM.
behalf of which the person(s) acted, executed 'IY IMIIl s b!'R 1
the instrument.
WITNESS my hand and official seal.
Signature
CIA—) (This area for official notarial seal)
MAIL TAX STATEMENTS TO:
SAME AS ABOVE;
i
i
fJ" t7
RC DISTRICT -PLANNING REVIEW FORM
This form is to be used by CDD staff for review of single family dwellings in'the RC (Cove Residential)
District, in order to determine the applicability of compatibility issues or need to require the filing of Master
Design Guidelines by the applicant. It shall be transmitted to the Building and Safety Department as your
correction list. Please attach additional explanations as necessary.
APPLICANT LENDEL VENTURES'. `aCc- -c
SITE ADDRESS 5j `venida Madero
APN 773 _ 113 _ 001 'BIN NO.: CASENO.: 2000-354
LEGAL: LOT BLOCK UNIT S.C.@V.L.Q.
CHECKED BY: Fred Baker DATE:
Inform the assigned Building plan checker upon your assignment to this case. The CDD Executive
Secretary maintains a log book to track applications and assign case numbers.
REQUIRED ITEM
Y
N
COMMENT/CORRECTION
Compatibility Review
Case logged and number assigned
Verify legal and APN information
Consistent with MDG on file (as.applicable
MDG filing required (5 filings since 9/3/98)
VED BY COMMUNITY DEVELOPMENT DEPT" '.-
Consistency with street/surrounding area:
Colors
Materials
Architecture
ATE 0
T
0.
JEXHI
Other Requirements:
J
Certificate of Occupancy
City of La Quinta
Building -and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the .City regulating building construction or use. For the following:
BUILDING ADDRESS:
Use Classification: SFD
Occupancy Group: R 3
51-620 AVENIDA MADERO
Type of Construction: VN
Owner of Building: LENDEL VENTURES
Building Official
Bldg. Permit No.: 0012-060
Land Use Zone: RC
Address:
P.O. BOX 450
City:
LA QUINTA, CA 92253
By:
STEVE TRAXEL
Date:
10-15-01
POST IN A CONSPICUOUS PLACE
Ads
Address
51680 Madero
s
La Quanta Realty
Mailing
Address same
LatyQuinta IZip
92253
Contractor
C.V. Roofing
P dreU. Bax 1255
&t�/
��
P.O. BOX 1504
78-105 CALLE ESTADO 1 �7
LA QUINTA, CALIFORNIA 92253
City .I Tel.:
Indio 9p2201 .398-5186
State Lic. City
& Classif. C39 352007 Lia # 329
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
Lic. #
LICENSED CON CTOR'S DECLARATION
I herebyyraffirrlhtl)at I am lice sed under prow ions of Chapter 9 (commencing with Section
7000),091AM � �of the Bust ass'na Professions Code, and my license is in full force and
effe 1.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
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 rile 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 five hundred dollars ($500). '
O 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
or 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) licensed pursuant to the Contractor's License Law.) -
❑ 1 am exempt under Sec. B. & P.C. for this reason
Dale owner
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.)
Pok�Cy No. Company
Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed 9 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 parson 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
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
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 It 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
'BUILDING: TYPE CONST.
A.P. Number
Legal Description_
Project Description
No. 10388
OCC: GRP.
Re Roof
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add O Alter ❑ Repair ❑ Demolition 0
L
Estimated Valuation 2880.00
PERMIT.
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
30.00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
30:00
REMARKS
n^cZ4k1q 1A Lt%c-, t 43-4J-04 +.o
_.-U-4~Nf't"1
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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 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL SO. FT. ® $
2ND FL SQ. FT.
POR. SO. FT. ®
GAR. SO_ FT. ®
CAR P. SQ. FT.
WALL SQ. FT. ®
SOFT ®
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 APPJEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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
SQ. FT. ® c
WATER HEATER
MAX HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/. c
SEWAGE DISPOSAL
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SQ.FT.GAR ® V4c
HOUSE SEWER
VENTILATION
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PLCK.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
cu. yd.
$ -Plus-x$-=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
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REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL