RER (9907-613) + RR (12577) + BLCK (003599)54120 Avenida Madero
9907-613
12577
003599
LICENSED CONTRACTOR DECLARATION
. I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
c W Professionals Code, and my License is in full force and effect.
=) C) License # Lic. Class Exp. Date
r- d u7
ILLIr
oZ r Date Signature of Contractor
O
J U C) OWNER -BUILDER DECLARATION
1-- Wd rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) /License Law for the following reason:
Z`f
_ " 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 contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
ce)Code). /7
LO () I am jbxempt under Section B&P.C: for this reason',_?
N em Signature of Owner/,;1_1
O rn
CL z WORKER'S COMPENSATION DECLARATION
C:) cc: I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X Lu L compensation, as provided for by Section 3700 of the Labor Code, for the
O Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
0- rn permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carrier Policy No.
ob Z)
a
J
(This section need not be completed if the permit valuation is for $100.00 or less).
(( y, 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 agree that if,,I,Should become
3 subject to the workers' compensation provisions of Sectio /3700 of the Labor
Code, I s all forthwith comply with those provisions.
,tate: if ^. lf1 `a Applicant rA-L-ti
Warning: Failure to secure Workers' Comp nsation 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.
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 authorize representatives Ot this City to enter upon
the aJ ove-mentioned property fo r{i nspection pt{rposes:) l
'vSignature (Owner/Agent) "` S - J Date -7/ Ztr l
R —I—
BUILDING PERMIT PERMIT#
DATE VALUATION LOT;7# TRACT
JOB SITE
APN
ADDRESS .54-120 AV .a lIDiA tt .IE110
774443-025
OWNER
CONTRACTOR / DESIGNER / ENGINEER
rlt9"sem B(.C( ,RR
OWNF 11 / BUILnkR
54120AVENIDA MP►i: EKE
LA QUtNTA CIA 9225-3
{,
USE OF PERMIT
fWSi1AN1'IAL kdhfbl{9FAL
REN.OW l CTM-SRAZINQ PAI i i ON WALL, Fd10CAYE H&M1A*.01J:i
VALUATION 4100.f10 1.3
If."'JAI. TED 4': .`+t'f OF f:.'UNSTi.fJf"TlON
fs iia r o i cel
ti
wiJ-ITY'i'AL CON' S11 st_"n0N AND PIAN t,;{}.i•K
f z r
1.ESS 1)RI PAH) F'FE.13
S000
"f'ti•LAL 11ERN4fI* Ill? t4'',fe-S 1)!!i,NOW
$15.0
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
Y
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
Partv Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final S
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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
Utility 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:
W
Building
Address 54-120 Madero
Owner Greg Butler
Mailing
Address ,si„ e
City Zip
La QUi>lta: CA 1 92253
Contractor
Owner/Builder
Address
P.O., BOX 1504
f 78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
BUILDING: TYPE CONST.
ty lZip Tela
State Lic. City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
564—OS08
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
70 OO) 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,Susiness 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 or 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 t e -applicant to a civil penalty of not more than five hundred dollars ($500).
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.)
O 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
ti -ate 9 .bd a o Owner 11L5 —
r r+
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. ❑ 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 whictj thip permit is issued, I shall not
employ any person in any manner so as to become sub* c
I to othe Workers' Compensation
Laws o Ca'fbrnia. r^ 1
bteOwner
NOTICE 0 APPLICANT., I/, after making his Certificate 67—ERemption you should become
subject to the Workers' Compensation provisions or the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
F
CONSTRUCTION LENDING AGENCY 4
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.
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 sof this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant —Date—
Mailing
ateMailing Address
City, State, Zip
P. Number
Legal Description
Project Description AF'r00f
- - 411PIV
No. 12577'.-,'
OCC: GRP.
Sq. Ft. No. No. Dw. ,
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ -Demolition ❑
Estimated Valuation $1,006.00
PERMIT
AMOUNT
Plan Chk. Dep.
,Plan Chk. Bal.
Const.
30.00
Mech.
Electrical
Plumbing
Grading
...
Driveway Enc.
Infrastructure
,r
TOTAL
30i 00 ,
REMARKS
ZONE: BY:
Minimum Setback Distances: T
Front Setback from Cientef Li.ne'.
( Rear Setback fro p . Line
S*de t Settk fr enter Line
Sid=k fro Pro Line
a i
FINAL DATE I'NAPE
4 -
Issued by: Date } Permit
Validated by: t
Validation: i✓" ,
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET i
ROOF DRAINS
CAR P. I SQ. FT. ®
GAS (ROUGH)
DRAINAGE PIPING
WALL SQ. FT.
OTHER APPJEQUIP.
DRINKING FOUNTAIN.
SQ FT ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
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
LAUNDRYTRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP k VSE 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.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SO.FT.GAR ® 3/ac
HOUSE SEWER
LATHING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEEMECH.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
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING f 2 Q. ^j
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL /'t -17-P)34
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
T4tyl 4 4 Q"
Building c ;
Address 5 / — : 1 ; -t r,3/'; r (
Owner
Mailing
Address . , 1 A, L
City Zip Tel.
77
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
MCI
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 Contractors License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
pemrft to construct, after, 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 aged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civilpenalty 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 krproves 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 witch 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 wfth a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec BS. & P.C. for this reason
Date A ti Owner t .'^'—
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. ❑ 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 fess.)
I certify that in the performance of the work for which this permit is issued, 1 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
1 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.)
Lenders Name
Lenders 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 certity that I have read this application and state that the above information is correct.
1 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
No. 05403
BUILDING: TYPE CONST. OCC: GRP.
-}
,A.P. Number -
,Legal Description
Project Description ' • 02 4 4' --
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation I
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
,
Mech.
Electrical
Plumbing
S.M.I.
c .;
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
i
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. ® $
UNITS
SLAB GRADE
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. SQ- FT. ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEQUIP.
DRAINAGE PIPING
CAR P. I SQ. FT. ®
TEMP. POLE
WALL SQ. FT.
GROUT
DRINKING FOUNTAIN.
FT ®
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
=$
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
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
VENTILATION
IKITCHEN 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.
SO. FT. ® c
BATH TUB
GAR. FIREWALL
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/. c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/<c
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
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
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 SIGNATURESIINITIALS
GARDEN WALL FINAL
_+26 P.O. BOX 1504 No.•
Building 78-105 CALLE ESTADO
Address -ter- 149 Madero LA QUINTA, CALIFORNIA 92253
Owner _
Mailing
Address
City Zip
Xs:,t re n?ZSR
Contractor
Address
BUILDING: TYPE CONST: OCC. GRP.
A.P. Number774-192-007
64--0508 Legal Description
Project Description ..5 t x75 9 Wood F'> nce
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 properly for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
HARD COPY
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:
City'
Zip
Tela
State Lic.
City
& Classif.
Lic. #
Sq. Ft.
No. No. Dw.
Size- -
Stories Units
Arch., Engr.,
Designer
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Address
Tel.
City
Zip
State
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.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
Estimated Valuation
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any, city or county which requires a
.637.50
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 Section 7031.5 for
Plan Chk. Dep.
violation of .by any applicant a permit
• subjects the applicant to a civil penalty of not more than -five hundred dollars ($500).
Plan Chk. Bal.
❑ 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
Const.
Professions Code: The Contractor's License Law does not apply to an owner of property .who
2)
•
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
-
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.I:
such projects with a confractor(s) licensed pursuant to the Contractor's License Law.)
.
Grading
❑ I am exempt under Sec.- B. & P.C. for this reason
Driveway Enc.
Date / 7 Owner' I' ( .1'1 t `
Infrastructure
WORKERS' COMPENSATION DECLARATION
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
O Copy, is filed with the city. O Certified copy is hereby furnished.
TOTAL
20.0¢
CERTIFICATE OF EXEMPTION FROM
REMARKS
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (8100) 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 OwneF'
" 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
comply with such provisions or this permit shall be deemed revoked.
Minimum Setback Distances: -
Front Setback from Center Line
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 properly for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
HARD COPY
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. ® $
2ND FL. SQ. FT. ®
POR. SQ. FT. ®
GAR. SQ. FT. ®
CAR P. SQ. 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
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APP./EQUIP.
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.
SO. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
REMARKS:
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 APP./EQUIP.
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
CERT. OCC.
I
l ENCE FINAL LI ` S
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL