9619 (SFD)Building
Address 78-62
T,iht 4 41Q"
P.O. BOX 1504
78-105 CALLE ESTADO
rcle LA QUINTA, CALIFORNIA 92253
Acacia
Mailing
Address 1021 Bastanchurv.Road
City [zip ITel. I
Fullerton 1 92633 1 714/992 -
Contractor
Acacia Construction
Address
City - lZip JTel.�
State Lic. City
& Classif. B -4923954 Lic. # 1612
Arch., Engr.,
Designer
Address Tel.
City Zip State
I I Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed,u'nder 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
a fect
I
SIGNATURE' DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractorjs License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alt., 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 permff
subjects the applicant to a civil penalty of not more than five hundred dollars ($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.) .
b 1, asowner 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
Workers Compensation Insurance, or a certifiedcopy thereof. (Sec. 3800, Labor Code.)
Policy No. Company.,
0 Copy is filed with the city. 0 Certified copy is hereby furnished.
I
CE RTIFICATE 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 thp work for which this permit is issued, I shall not
employ any person in any mi�nner so as to become subject to the Workers' Compensation
Laws of California.
Date -L- ' I owner �Fll,,' U
NOTICE TO APPLICANT, If, affet'makirig 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. 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 car tify 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
Maili * ng Address
City, State, Zi
No. 9619
WING: TYPE CONST._OCC: GRP.
P. Number
Description Lot 67
t Description Plan B3
ZONE: BY:
Minimum Setback Distances:
Front Setback from Cente ' r,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:
Sq. Ft.
Size 1721
No. No. DIN.
Stories Units
New 0 Add 0
Alter 0 Repair 0 -Demolition 0
Estimated Valuation
93,558
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
507.36
Const.
612.50
Mech.
53.50
Electrical'-
1103.66
Plumbing
120.50
S.M.I.
6.59
Grading
Driveway Enc.
Infrastructure
2105.06
AAr,11A9 1,11 977,� OA -94-91 14
TOTAL
0 3 SWU 1% TO 'AL i 350Y.i6
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Cente ' r,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
ROUGH PLUMB. BONDING
2ND FL. SO. FT. @
STORAGE TANK
YARD SPKLR SYSTEM
POR. SO. Fr. @
MOBILEHOME SVC.
BAR SINK
GAR. SQ. FT. @
POWER OUTLET
ROOF DRAINS
CAR P. SO. Fr. @
REINF. STEEL 7
DRAINAGE PIPING
WALL SO. Fr. @
DRINKING FOUNTAIN.
SO. FT, @
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
FINAL INSP.1 //F/qltf)
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
LUMBER GR.
FLOOR DRAIN
MECHANICAL FEES
FIRE ZONE ROOFING:
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
INSULATIONISOUND
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FENCE FINAL
LAUNDRY TRAY
AIR HANDLING UNIT CFM
IKITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET:
COMPRESSOR - HP
POLE, TEMIPERM
LAVATORY
HEATING SYST�M- 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 @ 11/4 c
I SEWAGE DISPOSAL
SQ.FT.GAR @ 3/4c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERM FEE
PERMIT FEE
DBIL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT.FEE
SMIFEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR'
SETBACK
GROUND PLUMBING UNDERGROUND
A.C. UNIT
COLL. AREA
V
SLAB GRADE
ROUGH PLUMB. BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
LIVIX-EWER OR SEPTIC TANR7 11 1 ROUGH WIRING.
DUCT WORK
ROCKSTORAGE.
FOUND. REINF.
GAS(ROUGH) Ile 6, 1 METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL 7
GAS (FINAL) TEMP. POLE
GROUT
WATER HEATER SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
FINAL INSP.1 //F/qltf)
FINAL INSP.
GRADING
—cu.yd.
$_plus_x$—=$
REMARKS:
LUMBER GR.
FRAMING
ROOFING
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
MHING 'Ic
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION IWO,
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS.
GARDEN WALL FINAL