9614 (SFD)ot
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 78-615 Carnes Circle LA OU I NTA, CALI FOR N I A 92253
k" 0 w n e r
Mailing
Address 1021 R&Igtanchnry C1
City lZip
Contractor
Address
City lZip FTe1_
State Lic. City
& Classif. B 2923954 Lic. # 1612
Arch., Engr.,
Designer
Address I Tel.
City Zip State
I 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 .
__ - _40
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
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 (5500).
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 safe. 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 1, as owner of the property, am exclusively contracting with licensed contractors to com.
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 ff the permit is for one hundred dollars ($100) vatuatian
or less.)
I certify that in the performance of thp v�ork for whi6h 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 wner
NOTICE TO APPLICANT ff, 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 affir m that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 309 7, Civil Code.)
Lender's Nam
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 cer tity 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 Addres
City, State, Zip
BUILDING: TYPE CONST
A.P. Number
Legal Description Lot 66
Project Description Plan A2
No.
OCC*. GRP.
9614
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Center Line
Sq. Ft.
Size 1162
No.
Stories
No. Dw.
Units
New 0 Add 0
Alter 0 Repair 0 -Demolition 0
FINAL DATE
—INSPECTOR
Issued by:
—Date Permit
Validated by:
Validation:
Estimated Valuation
74,631
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
446.3T
Const.
527.00
Mech.
47.00
Electrical
�190.61
Plumbing
120.50
S.M.I.
5.25
Grading
Driveway Eric.
Infrastructure
1679.19
.14
TOTAL
2915.89
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 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. @ $
UNITS
COLL, AREA
SLAB GRADE
JAY
YARD SPKLR SYSTEM
2ND FL. SO. FT. @
HEATING (ROUGH)
STORAGE TANK
FORMS Ay
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. @
DUCT WORK
ROCK STORAGE.
GAR. SO. FT. @
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SO. FT. @
GAS (FINAL) TEMP. POLE
WALL SO. Fr. @
DRINKING FOUNTAIN.
SO. FT. @
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
GRADING
-cu. yd.
$ -plus-x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
REMARKS:
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET�
COMPRESSOR HP
POLE, TEMPERM
LAVATORY
HEATING SYSTI�M- FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER. B.T.U.
SO. Fr. @ c
BATH TUB
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. Fr. RESID @ 1% c
SEWAGE DISPOSAL
SO.FT.GAIR @ V4c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT EE
PERMIT FEE
DBIL
TOTAL FEES
MICRO FEE
MECH.FEE PILCK.FEE
CONST. FEE ELECT.FEE
SMIFEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR*
SETBACK
GROUND PLUMBING )Iqqt COUNDERGROUND
A.C. UNIT
COLL, AREA
SLAB GRADE
JAY
ROUGH PLUMB. BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS Ay
SEWER OR SEPTIC TAN . K) i (ROUGHWIRING.
DUCT WORK
ROCK STORAGE.
FOUND. REINFj
GAS (ROUGH)l/0�.2ft4(cb 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 b
FINAL INSP.
ROOFING
ea
1q"r'R
REMARKS:
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
4� lhl� 104(&1
Jlg_H�
INsuLATIONISOUND
FINISH GRADING
FINAL INSPECTION -
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURIESIIN[TIALS
GARDEN WALL FINAL