04578 (BLCK)_ .. 4578
P.O. BOX 1504
Building 78-105 51-790 Cortez LA QUINTAC
Address CALIFORNIA 92253
Owner
RiChaard Siddon -- Gregg Ka=an ,. -
Address
City
.
Contractor
Address
=City jZip I Tel.
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
•thereby 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
vw� ; effect., u,
�^ SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Susiness and Professions Code' Any city or county which requires a
permitto 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)
❑ 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 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-buoder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ 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.)
❑ 1 am exempt under Sec. B. & P.C. for this reason % ^
Date,;it!!llOwner'�Pb/FI
_ 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. - i Company
❑ Copy is filed with the city. ❑ 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
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
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 this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant • Date
Mailing Address
City, State, Zip
IL'DING: TYPE CONST.' - OCC. GRP.
'.'Number- . , .: _ ...773 153-0021&
Legal Description
Project Description 2 0 X 15o t of retaining *Rall
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
y
Issued by: Date Permit
Validated by:
Validation:
1
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - 416SESSOR S OFFICE, HARD COPY - FILE •
..S c.
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
$2r250
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.�$�
Mech.
Electrical
Plumbing
S.M.I.
.50
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
`
t1�1riiaai i_
740f1_Rt 21-88. , 10
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
y
Issued by: Date Permit
Validated by:
Validation:
1
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - 416SESSOR S OFFICE, HARD COPY - FILE •
..S c.
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO, PLUMBING FEES
IST FL SO FT 47 S
UNITS
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
SPKLR SYSTEM
2ND FL SO FT. qtYARD
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR SO FT. or
DUCT WORK
ROCK STORAGE
41
(FOUND. REINF.
�•i`/
POWER OUTLET
ROOF DRAINS
GAR SO. FT. Cr
HEATING (FINAL)
OTHER APP.IEOUIP.
REINF. STEEL
GAS (FINAL)
DRAINAGE PIPING
CAR P. I SO FT. a
WALL SO. FT. (d
WATER HEATER
DRINKING FOUNTAIN
FINAL INSP.
URINAL
SO. FT. rd
WATER SYSTEM
ESTIMATED CONSTRUCTION VALUATION S
GRADING
cu. yd.
$ plus x$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
ROOFING/ _ �C
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISHI
APPLIANCE DRYER
VENTILATION
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
I ILAUNDRYTRAY
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.
SO. FT. ® c
BATH TUB
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID a I'A: c
SEWAGE DISPOSAL
SO.FT.GAR @ 3/4c
HOUSE SEWER
FINISH GRADING
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 8 AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
R OR SEPTIC TAROUGH
WIRING
DUCT WORK
ROCK STORAGE
41
(FOUND. REINF.
�•i`/
Jr
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEOUIP.
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.
MING /
FINAL INSP.
ROOFING/ _ �C
(� �l ) A
IINI
�G
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR-
GAR. FIREWALL
LATHING
MESH
(,
a2IN -/2-' Q
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
,
• "^'�: fc�nt� .''ice.+vway7-s�usa` ",aYr.- w., Y.l. .. ,. .r"�'i �°'"t �.r',w-� . • � w. - .. .- ._7 t' r. .., w.. .. .. ..
f^
--k
Are
Buena Engineers, Inc.
79-811 Country Club Drive, Suite 4
Bermuda Dunes, CA 92201 • (619) 345-1588 / 328-9131
Client
Client Address
Client Phone
DATE °
JOB NO.
os r z
y✓' -r- T�_'
t:
ATION
k,"— Q
REFERENCE CURVE
CONTRACTOR
OWNER
WEATHER
TEMP.
o at AM
at PM
PRESENT AT SITE
� A,
A 5A
/2.7
//0-(,
TEST
NUMBER
TEST LOCATION
LOT
NO.
ELEVATION
FIELD TESTING
REFERENCE CURVE
MOISTURE
CONTENT
%
DRY
DENSITY
IbsJCu. ft.
MAXIMUM
DRY
DENSITY
%
MAXIMUM
DRY
DENSITY
Ibslcu.ft.
OPTIMUM
MOISTURE
CONTENT
%
� A,
A 5A
/2.7
//0-(,
9 Z
/go 0
80.
9Z
.,
-� .C. - : i-, ••`•: �1 ;7t,P>i1
.. •. �
X Ai<..i'! : o,!
��+oc
":.'PhY, r�f.�.,.w
r',...^.
`. 'a. ...
.,.
I �
D
IP 2
D
REMARKS:
By
35`9
LIENT REPRESENTATIVE SIGNATURE
FIELD REPORT
TECHNICIANS SIGNATURE