11949 (BLCK)P.O. BOX 1504
Building. 78-105 CALLE ESTADO
Address 53—S90 Vallejo LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address 1364 Roselawn Ave.
City f Zip Tel.
.Thousand Oakh 91362 1(8
Contractor
owner
Address.
Tela
State Lic. City
& Classif. Lic. #
Designer
Address Tel.
V
No. 11949
11LDING: TYPE CONST. OCC: GRP.
P. Number 774-163-01-0
4 379A-9222 Legal Description
Project Description 190' of 3' high betaini g wall
398' of 6' high block wall.
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencingwith 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 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, 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
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) o/
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation o/ Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
; 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. I/, however, the building
orimprovement is sold within one year o/ 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-
-_-`and struct the project. (Sec. 7044, BuSnesProfessions Code: The Contractor's License Law
does not,, apply to an owner o/ propertwho builds or improvesyfneon, and who contracts for
such projects with a contractor "(s) licdnseed`pursuant to the Contractor's License Law.)
❑ lap a empt�ungeS S c1 '21142M4- & P` o •hi"sw gason 02tl
WO R KERSPEN SATJON'DECLARATIO N
I hereby affirm that I have a e lficaPe"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.
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 thg 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
Ihereby 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
ateMailing Address
City, State, Zip
REMARKS
z3'= Y6ihPf�cwk�^i'ie 71tci� i
ZONE:
BY:
Minimum Setback Distances:
Sq. Ft.
Size
No.
Stories
No. Dw.
Units ,
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition i❑
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date Permit
Validated by:
Validation:
Estimated Valuation
4.70'a0
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
72 . Citi
Mech.
Electrical
Plumbing
-
S.M.I.
.50
,.,Grad' g
Driveway Eno.
Infrastructure
TOTAL
l2 •
REMARKS
z3'= Y6ihPf�cwk�^i'ie 71tci� i
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
1ST FL. SO. FT. @ $
UNITS
SLAB GRADE Gj
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND. FL. SQ. FT. @
FORMSQVV
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SQ. FT. @
FINAL INSP.
BOND BEAM �T12 3�
WATER SYSTEM
DRINKING FOUNTAIN.
WALL SQ. FT.
LUMBER GR.
FINAL INSP.
URINAL
SO. FT. @
ROOFING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
VENTILATION
IWATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
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.
SO. FT. RESID ® 1Va c
SEWAGE DISPOSAL
SQ.FT.GAR @ 3/ac
HOUSE SEWER
CERT. OCC.
GAS PIPING
PERMIT FEE
MIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FCONST.
rPL.CK.FEE
FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE / PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE Gj
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMSQVV
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM �T12 3�
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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL