9826 (SFD)P.O. BOX 1504
78-105 CALLE ESTADO
Building 78745 8745 Grand Traverse LA QUINTA, CALIFORNIA 92253 �} �
M. J. Brock
Mailing
Address 3380 Shelby Street
City Zip Tel.
Ontario 91764 564-0973
Contractor
Address
State Lic. City
& Classif. B412636 Lic. # 1890
Arch., Engr.,
Designer
Address Tel.
City IZip,(State
Lic. #
LICENSED;CONTRACTOR'S DECLARATION
I hereby affirm that I am,licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 ofdthe Busihless and Professions Code; and my license is in full force and
effect.�,� �� '� t moi` !„ri....•'�r�` rii/`^"; °''�!
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,Susiness 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 appllcant 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 five hundred dollars ($500).
O 1, 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. d, however, the building
or improvement is sold within one year of completion, the owner-bugder wig 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 contractor(s) 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's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. I Company
Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(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
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 -of this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE CONST. OCC: GRP.•
A.P. Number
Legal Description Brock Homes
Project Description a Lot 54
Sq. Ft. No. No. Dw.
Size 7204 Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
ti
Estimated Valuation
151,037.00
PERMIT AMOUNT
Plan ,Chk. Dep.
Plan Chk. Bal.
7034.0.3
Const.
856.50
Mech.
79.00
Electrical
121.00
Plumbing
162.50
S.M.I.
11.34
Grading
Driveway Enc.
Infrastructure
3623.34
Art in Public
352.53
T
TOTAL 5710.30
%l%
REMARKS
^61� 4 09 JA 744A (17- 7-4-•4S 4 !}
£aJl1 A
MAL AL 1
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. SQ. FT. ® $
UNITS
2ND FL SQ. FT.
SLAB GRADE -
YARD SPKLR SYSTEM
POR. SQ. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
R08F DRAINS
CAR P. Q. FT. ®
S ER OR SEPTIC
D AINAGE PIPING
i
WALL SO. FT.
I
KINKING FOUNTAIN,
SQ FT ®
S OUGH)9--
C
URINAL
ESTIMATED CONSTRUCTION VALUATION $
HEATING (FI AL)
WATER PIPING
NOTE: Not to be used as property tax valuation
REINF. STEEL
FLOOR DRAIN
MECHANICAL FEES
\ MP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIG
WASH ER(AUTO)(DI SH)
APPLIANCE DRYER
V� GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE P MIT SVC
/ WATER CLOSET
COMPRESSOR HP
POLE, TEMIPER
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER. B.T.U.
SO. FT. ® c
BATH TUB
�,
SQ. FT. ®c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID A 1V. c
SEWAGE DISPOSAL
FIREPLACE
SQ.FT.GA ® V4c
HOUSE SEWER
SPARK ARRESTOR
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PLCK.F
CONS EE ;ELjr5fdT. EE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL \ H4TING & AIRbOND. SOLAR
SETBACK
ND PLUMBI
-fie UNDERGROUND
.C. UNIT
COLL. AREA
SLAB GRADE -
�j�
ROUGH PLUMB.
NDING
EATING (RO GH)
STORAGE TANK
FORMS
S ER OR SEPTIC
fANK RO H WIRING.
DUCT WORK
I
ROCK STORAGE
OUND. REINF. L1 'Z� �
CCC
S OUGH)9--
C
METE
LOOP
HEATING (FI AL)
1
i
OTHER APPJEOUIP.
REINF. STEEL
GAS ( NAL)
\ MP.
LE
GROUT
WATER EATER
SERVI
FINAL INSP
BOND BEAM
1
WATER S STEM
FINAL INSP.
GRADING
Cu.
$'lus
x$I
$
LUMBER GR.
RAMING —l/ /
--OOFING G
�lll
t.y
�,
REM RK
1
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
NSULATION/SOUND2— r
FINISH GRADING 2
FINAL INSPECTION -
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL