06209 (BLCK)P.O. BOX 1504 No, 06209
ng 78-105 C
LA QUINTACAL CALIFORNIA 92253
Ss s3-Qb� .R�1�.x�..
rhe 4 r
BUILDING: TYPE CONST.
OCC: GRP.
Mailing
Address P. 0. Box 59
A.P. Number
774-032--003
City
Zip
Tel.
La QItt eta
92253
554-I4&
Legal Description
Project Description
Sol X 4' Retainine will
Contractor
General. Rztract manam-ment
'
Address
y
R
City
Zip
Tela
State Lic.
& Classif. 514325
City
Lic- # 1235
Sq. Ft.
No. No. Dw.
Size
Stories -Units
Arch:, Engr-,
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Designer
Address
Tel.
City
Zip
State
Lic. #
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) t.of Division 3 of the Business and Professions Code, and my license is in full force and
effec
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the following
Estimated Valuation
$916reason:
(Sec. 7031-5,8usiress and Professions Code: Any city or county which requires a
permit to construct, after, irprove, demolish, or repair any structure,. prior to its issuance also
requires the applicant for such permit to We a signed statement that he is licensed pursuant to
the provisions of the Contractors 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 um7 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 Contractors 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 irprovaments are not intended or offered for sale. If, however, the building
' or improvement is sok/ within are year of cortpletion, the owner-bugder will have the burden
of proving that he did not bald or "reprove for the purpose of sale-)
PERMIT
AMOUNT
Plan Chk. Dep.
,
Plan Chk. Bal.
Const.��•
u
Mech.
Electrical
Plumbing
❑ 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 buaids or improves thereon, and who contracts for
such -projects with a contractor(s) icersed pursuant to the Contractor's License Law.)
O 1 am exempt under Sec B. 8 P -C- for this reason
r
S -M.1 -
,
Grading
-
Driveway Enc.
" Date owner
Infrastructure
WORKERS COMPENSATION DECLARATION '
Whereby affirm that 1 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- ❑ Certified copy is hereby furnished-
TOTAL
:! CERTIFICATE OFEXEMPTIONFROM
S
s WORKERCOMPENSATION INSURANCE
(This. sectkm need not be conptieted ff the per.* is for one hundred dollars ($100) valuation--
REMARKS�
-VT rmtt
"
aux
Yorless.) '
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: fl, after mafmg this Certificate of Exemption you should become
subject to the Workers' Compensation provsions of the Labor Code, you must forthwith
comply with such Prov mm or this permit shag be deemed revoked-
ZONE:, BY:
Minimum Setback Distances:
Front.Setback.from.Center Line
Rear Setback from Rear Prop. Line
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 Line
Side Setback from Property Line
Lender's Address
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 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-
FINAL DATE
Issued by:
Validated by:
INSPECTOR
Date I ! 7 Permit
Signature of applicant Date'
" Mailing Address
Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL SO. FT. ® $
2ND FL SO. FT.
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. I 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(AUTOXDISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPIEOUIP.
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% c
SEWAGE DISPOSAL
SO.FT.GAR ® V4c
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
@eOUND. REINF.,S-- — �y—��
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPIEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
Z16OND BEAM �— �U
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.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL