04004 (SATT)4 Qa4z 04004
P.O. BOX 1504 ?r
Buildin78-105Addrress 54-56x5 '�'i�XlglGwood LA QUINTACCALIFORNIA 9225. 3
Owner
Mailing.
s iso Company BUILDING:"TYPE CONST. OCC. GRP.
Address 75-005 Country Club Dr. ,_ _ w A.P:..Number. . _VGA West - The Gree
City Zip Tel. r.
P�t�.m Do�sor 9226 3 , ,��d�'w�,��� � Legal Description
Contractor �j y�g�/��y► y Project Description ��.n AUR P3ra$Pd 2G
National mortcl4ae M a r n
Address
Sam
City Zip Tel.
State
Cla sif. 288130 Licy
&# 320 . y Sq. Ft. • 1598 No. - No. Dw.
Arch., Engr., Size Stories Units
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demoliion ❑
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commending with Section
7000) of Division 3 of the Business and Professions Code, and my license. is in full force and
effect. ( _ I
SIGNATURE DATE
OWNER -BUILDER DECLARATION Estimated Valuation 4• {qy�
I hereby affirm that I am exempt from the Contractor's License Law for the following f d i
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 PERMIT AMOUNT
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 Secticn 7031.5 by Any applicant for a permit Plan Chk. Dep.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500). [s1
❑ 1, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal. 0 385 .54
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const. 470 �1
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, :1
Mech. `9
provided that such improvements are not intended or offered for sale. If, however, the building 3r '•/
or improvement is sold within one year of completion, the owner -builder will have the burden Electrical 70..46
of proving that he did not build or improve for the purpose of sale.)
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing $7,00
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 S.M.l. $ y 013P
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading
O 1 am exempt under Sec. B. & P.C. for this reason
Driveway Enc.
Date Owner Infrastructure 2o569.03
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
❑ Copy is filed with the city. O Certified copy is hereby furnished. •' t
TOTAL r✓.+..iww s,vwr ,: e"i.;
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation -0- r. A±'' . A fin+, n 1 n A: Jc,r nM e, 1*11
or less.) . $'t� ..: x �;F� ,7, e � r w �•f3s'i' .:7"�• •�
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any parson 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 ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances:
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) Side Setback from Property Line !r
Lender's Name
Lender's Address FINAL DATE—INSPECTOR
This is a building permit when properly filled out, signed and validated, and is subject ton� �y A
expiration it work thereunder is suspended for 180 days. rF 09
1 certify that I have read this application and state that the above information is correct. Issued by: Date Permit
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. Validated by:
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY.- FILE
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL SO FT (p b
UNITS
SLAB GRADE
ROUGH PLUMB
BONDING
YARD SPKLR SYSTEM
2ND FL SQ FT. a
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR SO FT. a
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR SO. FT. to
TEMP. POLE
GROUT
DRAINAGE PIPING
CARP. SO FT. fa'
FINAL INSP.
BOND BEAM
WATER SYSTEM
DRINKING FOUNTAIN
WALL SO. FT. Q
=b
LUMBER GR.
FINAL INSP.
URINAL
SO. FT. a
ROOFING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE, Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
VENTILATION
WATER SOFTENER
VENT SYSTEM FAN EVAP.0OOL HOOD
SIGN
WASH ER(AUTOXDISH)
APPLIANCE DRYER
FIREPLACE
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
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.
SO. FT. ® c
BATH TUB
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT. B.T.U.
SQ. FT. RESID @ 1 V. c
SEWAGE DISPOSAL
SO.FT.GAR q 3/4c
HOUSE SEWER
CERT. OCC.
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
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
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.
b -plus-x$
=b
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 SIGNATURES/INITIALS
GARDEN WALL FINAL 7d