14552 (BLCK)Building
Address
Owner
f
P.O. BOX 1504
78-495 ALLE
79-160 Coyote Creek LA QUINTACCALIFORNIA 902253
14Inistrelli Construction
Mailing
Address 50-44 Mountain Shadows
City Zip Tel.
La gumma, C32253541849
Contractor
sain£
..Address
State Lic. B IgCity
& Classif. _ �A3 ,� Lic. #
Arch.; Engr.,
Designer
Address Tel.
City Zip State
, 1. 1 . ... . Lic. #
LICENSED CONTRACTOR'S DECLARATION .
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section •
000) of Division 33 of Iffe Business and Professions Code, and my license is in full force and
effect8''9','....r„��„r^� emu �w'i�.r -� �;. ,�pr•^ � ..,�•
SIGNATURE %_ -11 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, 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 rive 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, Butsness 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 yearof completion, the owner -builder 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 contractors) licensed pursuant to the Contractor's License Law.)
O 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'sCo 'sensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) . .
Policy N Company
i. I! opy Is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need -,not be completed B the permit is for one hundred dollars (8100) valuation
or less.) "
I certify that In the performance of thg'work for which this permit is issued, I shall not
employ'any peon in any manner so as to become subject to the Workers' Compensation
Laws of Cali forrsnia.
Date Owner
NOTICE TO APPLICANT: If, after me"' this Cerlificate"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.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
I SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
I HUNDRED THOUSAND DOLLARS (5100,000), IN ADDITION TO THE COST OF COMPENSATION,
i DAMAGES AS PROVIDED FOR IN -SECTION 3706 OF_ -THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I ' 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 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
No. 14552
BUILDING: TYPE CONST. •OCC. GRP.
P. Number
Legal Description
Project Description 370 1. f.. o1= 5' high garden
block•gall
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation M250.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
217.04
Mech.
Electrical
Plumbing
S.M.I. -
Grading
Driveway Enc.
Infrastructure
TOTAL
U7.00
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from CenteLine
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. PLUMBIW FEES
IST FL. SO. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SD. FT.
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SO, FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. I S0. FT.
TEMP. POLE
DRAINAGE PIPING
WALL SO. FT.
GROUT
DRINKING FOUNTAIN
SO. FT. ®
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as properly tax Valuation
_$
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
VENTILATION
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ®c
BATH TUB
GAR. FIREWALL
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® V4c
HOUSE SEWER
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 CON D. 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
�y
LIND. REINF. .4
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
VLAPOND BEAM 3 S
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 SIONATURESJINITIALS
GARDEN WALL FINAL