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11759 (PLBG)Tity/ 4 �IG1�'GIGV. P.O. BOX 1504 Buildin78-105Addrress 52-484 Vallejo LA QUINTACCALIFORNIA 92253 Owner R.L. Pendergraph Mailing Address Same City Zip Tel. La. Quinta, 4 92253 _ 1,.564-7467 Contractor Owner/Builder Address •. Same City Zip Tela State Lic. City & Classif. Lic. # .._._.Arch.-, Engr. Designer Address •1 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. SIGNATURE DATE OWNER -BUILDER DECLARATION I hereby affirm that l am exempt from the Contractor's License Law for the following reason: (Sec. 7031.5,Business and Professions Code: Any city orlcounty which requires a permit to construct, alter, Improve, demolish, or repair any structure;l 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 4 t:for,; the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit - � �'sirbjects the applicant to a civil penalty of not more than five hundred dollars (8500). ;Y Gjh, as owner of the property, or my employees with wages'as their sole compensation, will " dWhe 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, 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.0 for this reason A' Z11 _,., 6 A { Date i 7Z. 'r owner X1.1 'V1`r t ►' ��� a , 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. ❑ 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 (8100) valuation or less.) I certify that in the performance of tho 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 sof this city to enter the above-. mentioned property for inspection purposes. . Signature of applicant Date Mailing Address City, State, Zip BUILDING: TYPE CONST. A.P. Number Legal Description Project Description No. OCC: GRP. - 10 . RP. Sewer connect 11759 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: Sq. Ft. Size No. No. Dw. Stories Units New ❑ Add ❑ Alter ❑ Repair-❑ Demolition ❑ Estimated Valuation $1,000.00 PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. y Const.-.',,,, , Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure - w TOTAL t •'' 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 IST FL. SO. FT. ® $ UNITS COLL. AREA SLAB GRADE YARD SPKLR SYSTEM 2ND FL. SO. FT. ® HEATING (ROUGH) STORAGE TANK FORMS MOBILEHOME SVC. BAR SINK POR. SO. FT. ® DUCTWORK ROCK STORAGE FOUND. REINF. POWER OUTLET ROOF DRAINS GAR. SO. FT. ® HEATING (FINAL) OTHER APPJEOUIP. REINF. STEEL DRAINAGE PIPING CARP. SO. FT. ® GROUT DRINKING FOUNTAIN. WALL S0. FT. FINAL INSP. BOND BEAM URINAL SO. FT. @ GRADING cu. yd. $ plus x$ _$ ESTIMATED CONSTRUCTION VALUATION $ FINAL INSP. WATER PIPING NOTE: Not to be used as property tax valuation ROOFING FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.000L HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER VENTILATION GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED FIRE ZONE ROOFING LAUNDRYTRAY AIR HANDLING UNIT CFM FIREPLACE 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 ® 11/4 c SEWAGE DISPOSAL SO.FT.GAR ® 3/ac HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE EPL.CK.FEIE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR SETBACK GROUND PLUMEING UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWERAFFBEPW49.40NK OUGH WIRING DUCTWORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEOUIP. 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 FINAL INSP. ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTION 2N93 CERT. OCC. FENCE FINAL INSPECTOR'S SIGNA'URESIINITIALS GARDEN WALL FINAL Account N Service Ad r-1 ❑ Service(s) ❑ Backflow(s) ❑ House Lateral(s) ❑ DetectorCheck(s) ❑ Meter Surcharge Sanitation Capacity. Charge ❑ W.S.B.F.C. ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee - Tract - Fee - ❑ Plan Check Fees Water / Sewer - Tract - ❑ Bond Payment - A.D. - Bond Assmt. ❑ Customer Deposit ❑ Other Remarks: ❑Copy to: Cash Check Money Order TOTAL $ S ef)U Water Service Cashier � � C -438(11189).