RPL (001781)P.O. BOX 1504
Building O
54-,218 AVenii t � LA QUINTAC
Address CALIFORNIA 92253
Owner
Stme PAbolf
Mailing
Address Sam
City Zip Tel.
La eta 92253 564-4584
Contractor
SLUNLIX X13
Address
P.O. Box 835
City Zip Tel.
pa0M
Xt 9226] 56284014
State Lic. City
& Classif. O 53 397252 Lic. #
Arch., Engr.,
Designer
Address I Tel.
IM22 E Acacia (213) 636-0294
City Zip State
a9rcim tic vp- I Lic. # 10193
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under, provisions of Chapter 9 (commencing with Section
7000) of D,iv`ision 3 of the Business,and Professions Code, and my license is in full force and
effect R_] fir` / f V 1, r
SIGNATURE - r 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 five hundred dollars ($500).-
0
$500)'0 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.)
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
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
0 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
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
0 Copy is filed with the city. 0 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 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.
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
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 thts city to enter the above-
mentioned property for inspection purposes.'
Signature of applicant �� f Date
Mailing Address f /'f v
City, State, Zip e -.-
HARD COPY
No. 001781
BUILDING: TYPE CONST. VN OCC. GRP. R3
A.P. Number 7714--223-'011 & 012
Legal Description
Project Description 17' x 30= so0l and 5' x IS =a
REMARKS
ZONE:
A'.YV 1liG {. r6iY.
rrrc�JLy. ti irf.Y.yJi
Front. Setback from Center Line
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
FINAL DATE
INSPECTOR
Issued by:
DatePermit
Validated by:
Validation:
A3110
11 _6 254.81 CK
Estimated Valuation
$ 15,250.DQ
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
7y.72
Const.
1,16.50
Mech.
17.Sil)
Electrical
Plumbing
f31
S.M.I.
t grlq
Grading
Driveway Enc.
Infrastructure
TOTAL
74!! _ f e 1
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:
DatePermit
Validated by:
Validation:
A3110
11 _6 254.81 CK
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
t
IST FL. SO. FT. ® $
2ND FL. SD. FT.
POR. SQ. FT. p
GAR. SO. FT. ®
CAR P. SO. FT.
WALL SQ. 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
ROUGH PLUMB.
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
GAS (ROUGH)
LAUNDRY TRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
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
BOND BEAM
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
LUMBER GR.
SQ.FT.GAR ® 3/ac
HOUSE SEWER
FRAMING
FINAL INSP.
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 2v / f; ��
V
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
1 (eREINF. STEEL'Z
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
%� O
�/�//C�j7 �•
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