PLBG (9701-089) + PAT (07511) + RPL (07392)44310 Marigold Lane
9701-089
07511
07392
-LICENSED CONTRACTOR DECLARATION
I hereby, affirm under penalty of perjury that I ani 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
bate•. / Signature of Contractor 71a .
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 contracting with licensed
contractors to construct the project (Sec. 7044, Business .& Professionals
Code).
O I am exempt under Section' k' , 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 willmaintain workers' compensation insurance, as •required by
Section 3700 Of the will.
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 so'as to become subject to the
workers' compensation. laws of California, and agree that if l .should become
subject to the workers' compensation provisions of Section 3700 of the Labor.
Code, I shall forthwith comply with h e provisions.
ate: if Applicant.-+
Warning: Failure to secure Workers' Compensation 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 applicationbecomes 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 of this City to' enter upon
the above-mentioned property for inspectio fpu o es.
&,Sig ture (Owner/Agent) Date 7
• BUILDING PERMIT FERMT# °°NTR°`# .
'4
► ra Q_ a 3 5
-
DATE rl gi VALUATIONry( LOT' TRACT -
JOB SITE
DDRESS4-.ta ',T1i 1 ii I :iJ ,.i?
APN ..
:OWNER
CONTRACTOR / DESIGNER / ENGINEER
C ARSB: K MOORE .:
VALLf Y PsaC.Jt!=tt. ING
44.310 NI iMt CJLD :. ..
PO Box 66:5
( A. . 1111+t.t . c„'i 92253
i!t f,DtO CA. 1021
COU .
USE OF PERMIT
%s'11r% t11'iail3 'I< +;r.iwr d.Fa
.E ,.S' 'E lt : ?,. rh a; 3' C't` ILiw' E1t"rIO10
` y+
"."K 1_9.gd
gy syr}p q
P11, F 1. 41 . ,F E r,6d 1 `l i itARV
.........
rn
rn
1.r.NwR:
fXSS PRf —PAID `t'1.:1 5
$0100.-...
W07A , $.Efts' UT F1n1,R4DU F,'!SOW
RECEIPT
DATE'
BY .
DATE FINALED
INSPECTOR
INSPECTION RECORD
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
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
J
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:
_
4
P.O. BOX 1504
Building 44-310 Tari`61d 7&105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
J. Carson ire & Betty Nom _
Mailing
Address76-786 Dish Piaae
City IZip ITel.
Contractor
Address
Zip I Tel.
State Lic: City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 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
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
' `'fA•quires 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).
0 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 'orrImproves-.ihereon 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 contrac(or(s) licensed pursuant to the Contractor's License Law.)
0 1 am exempt under Sec. -7B. & P.C. for this reason
Date f net
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
0 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(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.
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 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
ateMailing Address
City, State, Zip
No. 07511.
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number Cactus never
Legal Description
Project Description Patio Cover
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 4'6JW Permit
Validated by:
Validation:
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
$2,48
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
35.10
Const.
54.00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
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 4'6JW Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST 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
MOB]LEHOME 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 APPJEOUIP.
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.
SO. FT. RESID ® 1% c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
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 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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL ::d
r
• i '.
!t'. - i. • - - ' 4 M s -
^; P.O. BOX 1504 No. - 0732
rBuilding
78-105 CALLE ESTADO -
' Address 44 -310 -Ma rigdld _ ,LA QUINTA, CALIFORNIA 92253
' Owner
Cars"' HoOTm
BUILDING: TYPE CONST. OCC. GRP. - ;.
Mailing +
Address 44- 10 Marl -cactus Flower-
_ ,. _ .. w A.P..Number
_ . Lot. 46 Tract 982
City, Zip TeL
T ciL1` a ; 93.._ :'. _.._360 766 -• - Legal Description
Contractor ;' Project Description '
unique :Pools' by Canrine
Add
• City ~' Zip Tel.:
' ftlm Desert 92260 _.. 346-6335r
State Lic.
City
• & Classif.
Lic. #
Lic. • 1366
Sq. Ft. No. No. Dw:.
Size Stories i - -- Units
' Arch., Engr.; . s' ... .
New ❑Add ❑: Alter E3: Repair.❑ Demolition ❑
Designer - ,.
Address . -
r
Tel.
-
r
,
City
Zip
State
...
Lic. #
"
LICENSED CONTRACTOR'S DECLARATION
• - I hereby affirm that I am licenied under provisions of Chapter (commencing with Section '
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
'
SIGNATURE p DATE
OWNER -BUILDER DECLARATION
I hereby affirm •that I am exempt from the Contractor's License Law for the following
Estimated Valuation
reason: (Sec. 7031.5,Bus-mess and Professions Code: Any cityor county which requires. a
-
Permit to construct, alter, bnprove, demolish, or -repair any structure, prior to 8s issuance also
-AMOUNT
- requires the applicant for such permit to rile a signed statement that he is licensed pursuant to
,PERMIT - . '
-
the provisions of the Contractor's license Law, Chapter 9 (commencing with Section 7000) of
-
D44sion 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
:Plan Chk. Dep. '
subjects the applicant to a civil penally of not more than rive hundred dollars (5500).
❑ 1, the
-
Plan Chk. Bal. 52.65
as owner of property, or my employees with wages as their sole compensation, win
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code:, The Contractor's
"•
Const. _ 81.00
License Law does not apply to an owner of property who
builds or mproves thereon and who does such work himself or through his own employees,
provided Nat such improvements are not intended or offered for sale. If, however, the building
Mech. 30.00 -
or improvement is sold within one year of completion,• the owner -budder will have the burden
m
ElectricalL -
00
- of proving that he did not build or Improve for the purpose of sale.) ...
•
Plumbing _ 4 (fig
❑ I, as ownerof 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
S.M,I. _•• i1
•Y
such projects with a contractor(s) licensed pursuant to -the Contractor's License Law.) - ..
Grading -
. ❑ I am exempt under Sea B. ii P.C. for this reason
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.)
Policy No. Company
,- ❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
A+4
TOTAL
- CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE°y ^,*-
REMARKS
(This section need not be completed N the permit is for one hundred doliars (S 100) valuation
" y
- .R ,l v J. S, ik Y 3 IDTA" t- rAAi
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
4 _
Laws of California
Date Owner '
T
ZONE: BY:
NOTICE TO APPLICANT. If, after making this Certificate of Exemption you should become
subject' to Me 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
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY ` ' "-
Side Street Setback from Center. Line '
I =firm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec 3097, Civf1 Code.)
Side Setback from Property -Line
Lender's Name
-
Lenders Address
.,FINAL DATE - INSPECTOR' • ,
3/22190 "
' This is a building permit when property 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.
1
Issued by: -Date Permit
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_ r
Validated by: m•
Signature of applicant Date' ' j
. , Mailing.Address
Validation:
City,- State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® =
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT.
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING.
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I SQ. FT. ®
GROUT
WATER HEATER
WALL SD. FT.
FINAL INSP.
DRINKING FOUNTAIN.
SQ FT ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
=$
WATER PIPING
NOTE Not to be used as property tau valuation
/tee
FINAL INSP. r `7
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTONDISH)
APPLIANCE DRYER
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.
SQ. FT. RESID ® 1% c
SEWAGE DISPOSAL
SQ.FT.GAR @ 3/ic
HOUSE SEWER
FINISH GRADING
GAS PIPING
PERMIT FEE
PERMIT FEE
ni
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE 7NST.
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 APPIEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
/tee
FINAL INSP. r `7
FRAMING
FINAL INSP.
ROOFING
D
REMARKS:
VENTILATION
FIRE ZONE ROOFING,
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESlINITIALS
'
GARDEN WALL FINAL
Tjbt 4 4 Q"
Building 0
Address 444-3iS MarlRo d Laim
Owner
Mailing
Address 43-875 Washington Sat
City Zip Tel.
P.D. 92260
Contractor
H.G. Willilms Dev. Corp.
Address
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
No.
.. r
BUILDING: TYPE CONST. OCC: GRP.
City Zip Tel.'
State Lic. City
& Classif. 493919 Lic. # 1231
Arch., Engr.,
Designer
Address I Tel.
City( Zip ( State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
70IN of Division 3 of the Business and Professions Code, and my license is in full force and
effect. 7
_SIGNATURE DATE
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 or county which requires a
permft 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 hes 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 therermm, and the basis
for the l 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 (5500).
❑ 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 inproves 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 wig have the burden
of proving that he did not build or improve for the purpose or 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 pro%acts with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy 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 if the permit is for one hundred dollars ($100) valuation
or less.)
1 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 Califomia
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemptionyou 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.)
Lenders 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 certity 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, Stale, Zip
IA.P. Number
05909
Legal Description Phase II tot 46
Project Description Pian OR Caetue ?lower
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
6-15-89
Issued by: Date Permit
Validated by:
Validation:
Sq. Ft. 1887
Size •
No.
Stories
No. Dw.
Units
New& - Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
88,500.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
494.40
Const.
590.00
Mech.
53.50
Electrical
113.71
Plumbing
123.00
S.M.I.
6.23
Grading
Driveway Enc.
Infrastructure
2221.98
TOTAL
REMARKS
twit ft') 4
7 1A i''1A- •r'±9 _ _ i (
4d fi.P3:i:1
'x (frit U.
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
6-15-89
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® $
UNITS
SLAB GRADE 7/•L!
OUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT.
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH) ' Z •1
ER LOOP
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL) /
EMP. POLE
DRAINAGE PIPING
CAR P. I SQ. FT. ®
GROUT
WATER HEATER
WALL SQ. FT.
FINAL INSP.
DRINKING FOUNTAIN.
FT ®
WATER SYSTEM
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
ROOFING
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOXDISH)
APPLIANCE DRYER
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, TEM/PERM
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.
SQ. FT. RESID ® 1% c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
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 PLUMB IN O
UNDERGROUND
A.C. UNIT
COLL AREA
SLAB GRADE 7/•L!
OUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCKSTORAGE
FOUND. REINF.
GAS (ROUGH) ' Z •1
ER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL) /
EMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
FINAL INSP.
FINAL INSP. j/
GRADING
cu. yd.
$ -Plus-X$-=$
LUMBER GR.
FRAMING iC) (Z A57(
ROOFING
OF
p/
/
tA-
J
t
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING ( tg
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
1