08704 (PAT)Building
Owner
C&t!t 4a �
P.O. BOX 1504 i` F Q
Mailing
Address
City Zip Tel.
I
City
Lic. #
Tel.
State I
Lic. #
LARATION
DATE
is License Law for the following
structure, prior to its issuance also
died dollars ($500).
e.)
over theregn!arid �who,contracts for
'\44
reason t
N FROM
INSURANCE
ch this permit is issued, I shall not
act to the Workers' Compensation
.l
nd state laws relating to building
this city to enter the above-
is exempt therefrom, and the basis
/or the alleged exemption. Any violation o/ Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than live hun
O I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
apply to an owner o/ property who
g with licensed contractors to
Code: The Contractor's License Law
t to self -insure, or a certificate of
one hundred dollars ($ 100) valuation
e Labor Code, you must forthwith
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
Contractor
Owner/Builder
Address
City Zip � Tel.
State Lic.
& Classif.
Arch., Engr.,
Designer
Address
City IZip
statement
Professions
himself
offered
con-
struct the project. (Sec. 7044, Business and Professions
does not apply to an owner of property who builds or improves
such projects with a contractor(s)
hereby furnished.
LICENSED CONTRACTOR'S DEC
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
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
reason: (Sec. 7031. S,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any
requires the applicant for such permit to lila a signed
that he is licensed pursuant to
the provisions o/ the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 0l the Business and Professions Code, or that. he
Code: The Contractor's License Law does not
builds or improves thereon and who does such work
or through his own employees,
provided that such improvements are not intended or
/or sale. I/, however, the building
or improvement is sold within one year o/ completion, the owner -builder will have the burden
o/proving that he did not build or improve for the purpose o/sal
❑ I, as owner of the property, am exclusively contractin
licensed pursuant to the Contractor's License Law.)
❑ I am exempt under Sec. � B. t. P.C. for this
Date /t; Owne�
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consen
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. O Certified copy is
CERTIFICATE OF EXEMPTION
WORKERS' COMPENSATION
deemed revoked.
(This section need not be completed i/ the permit is for
or lass.)
I certify that in the performance of thg work for whi
employ any person in any manner so as to become subject
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, ager making this Certificate o/ Exemption you should become
subject to the Workers' Compensation provisions o/ th
comply with such provisions or this permit shall be
-Date-
Mail i ng. Addres
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 a
construction, and hereby authorize representatives sof
mentioned property for inspection purposes.
Signature of applicant
ate08704
Mailing,Address
City, State, Zip
OCC. GRP.
A.P. Number
Legal Description
Project Description
VATTO ch"t?
Sq. Ft.
Size 4$;p
No. No. Dw.
Stories I Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
17
Q
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
72. 00
Mach.
46. 80
Electrical
Plumbing
S.M.I.
.35
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 Perm
Validated by:
Validation:
T
CONSTRUCTION ESTIMATE
NO. ' ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. @ $
UNITS
COLL, AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. @
DUCT WORK
ROCK STORAGE
GAR. SQ. FT. @
POWER OUTLET
ROOF DRAINS
CAR P. SQ. FT. @
HEATING (FINAL)
DRAINAGE PIPING
WALL SQ. FT. @
DRINKING FOUNTAIN.
SQ FT @
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FINAL INSP.
LAUNDRYTRAY
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
FIREPLACE
SQ. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID @ 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR @ 3/ac
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE LPL.CCK.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
/
►'� I'}.
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION' i�
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL