08979 (SFD)Building
Address
Owner
Mailing
Address
City
Contractor
Address
City
State Lic.
& Classif.
Arch., Engr.,
Designer
Address
City
P.O. BOX 1504 N o .
50-085 Qrand WaVOt6$ AM. LA OUINTAC
50-085CAL FORNIA 92253
s
BUILDING: TYPE CONST.OCC: GRP.
250 Riv eon S A.P. Number
Zip Tel.
Comm 9I Legal Description �....�es..,�
Project Description *.4^1 ACR Tar 'AQ
�r
Zip Tela
__
City
Lic. # Sq. Ft. No. No. Dw.
Size 3017. . Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Tel.
Zip State
Lic. #
CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed u
7000) of Division 3 of the.Business,a
effect.
OWNER -BUILDER -DECLARATION r
hereby affirm that I am exempt from the Contractor's License Law for the following
'!. treason: (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
,,,lrequires 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
x Division 3 of the Business and Professions Code, or thathe 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).
O 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 -builder will have the burden
of proving that he did not build or improve for the purpose of sale.) '
0 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 Owner
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
13�6py is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed i1 the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of lhg 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 it work thereunder is suspended for 180 days.
I certify that 1 have read this application and slate 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
Estimated Valuation
� 7
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const. t056,
Mech.
Electrical 151.14
Plumbing
S.M.I. 15.33
Grading
Driveway Enc.
Infrastructure 4922-12
TOTAL
REMARKS
00zn1l Z1. 10 707L JO
7 lrf I lufttL X f4tv.Yi
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:
T
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
SLABGRADE (_0
2ND FL. SO. FT.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEOUIP.
DRAINAGE PIPING
CAR P. I SQ. FT.
TEMP. POLE
WALL SQ. FT.
GROUT
DRINKING FOUNTAIN.
SQ. FT. ®
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
_$
FLOOR DRAIN
MECHANICAL FEES
{
INAL INSP. �. ``t/
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
VENTILATION
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/a c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
/.� INSULATIONISOUNDtj _oi r
v
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 COND. SOLAR
SETBACK
GROUND PLUM BI i
UNDERGROUND
A.C. UNIT
COLL. AREA
SLABGRADE (_0
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
EWER
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
AS (ROUGH)/G/�/
[
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
INS ITEECSGAS
(FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$
LUMBER GR.
{
INAL INSP. �. ``t/
))
FRAMING G _lU _� (
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
/�
BATHING C _ / n _"` j
MESH
/.� INSULATIONISOUNDtj _oi r
v
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL 7d