9825 (SFD)44
P.O. BOX 1504 � �� No.
9825
Building 76785 Grand Traverse 7&105 CALLS CALIFORNIAESTAD9 i
Address LA QUINTA, ORNIA 92253 t
Owner
H. J. Brooms
Mailing BUILDING: TYPE CONST. OCC: GRP.
Address 3390 Shelby Street
A.P. Number
City 1117643
TOntario 564-0973 Legal Description Broick Homes
Contractor Project Description I Lot 50
SAM
Address
City Zip Tel.:
State Lic. City
& Classif. B412636 Lic. # 1890 Sq. Ft. 2204 No. No. Dw.
Size Stories Units
Arch., Engr.,
Designer New ❑ Add ❑ Alter ❑ Repair 0 Demolition ❑
Address Tel.
City Zip State
r` Lic- #
•H �
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that,l-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
r .
effect.... /=�! �.'`�! f�-_..r ..e-r:,s'r � � � e� • -'•r r�/'i
SIGNATURE .+' DATE
OWNER-BUILDER DECLARATION Estimated Valuation
I hereby affirm that I am exempt from the Contractors License Law for the following 161,037.00
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 thealleged exemption. Any violation of Section 7031.5 by -any applicant for a permit Plan Chk. Dep.
subjects the applicant to a civil penalty of not more than rive hundred doliars.($500). '104.03
•03
O I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal.
do the work, and the Structure is not intended or offered for sale. (Sec. 7044,,Buisness and Const. _ 85-6.-5 0
Professions Code: •The Contractor's License Law does not appy. to an owner of property who ,
builds or improves thereon and who does such work himself or through his own employees,Mech. 19. {HCl
provided that such Improvements are-not intended or offered for sale- ff. however, the building Y rteyf�y
or improvement is sold within one year of completion, the owner-builder wig have the burden Electrical fr. .f: . Y V
of proving that he did not build or improve for the purpose of sale.)
O I, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing 162.50
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law 7 1 • 3
does not apply to an owner of property-who builds or improves thereon, and who contracts for S.M.I. s
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
O I am exempt under Sec. B. & P.C. for this reason Grading
Driveway Enc.
Date Owner Infrastructure 23 3 4
Art in ic'l bliC
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 .r
Copy is filed with the city. O Certified copy is hereby furnished. a
TOTAL SIIU.3u
CERTIFICATE OF EXEMPTION FROM REMARKS
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 lhp 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 Lu u:t>sr r z "e u e rzf_ x .r r �•� ..
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
comply with such provisions or this permit shah be deemed revoked. Minimum Setback Distances: ,
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
Lender's Name
Lender's Address FINAL DATE INSPECTOR
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: 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 fof inspection purposes. Validated by:
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
2ND FL. SO. FT.
ROUGH PLUMB.
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
SEWER OR SEPTIC TANK
ROUGH WIRING
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. SO. FT.
AS (ROUGH) �/ �,GJ
t o
DRAINAGE PIPING
WALL SO. FT.
HEATING (FINAL)
DRINKING FOUNTAIN.
SO FT ®
GAS (FINAL)
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER HEATER
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GRADING
cu. yd.
$ plus x$
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FINAL INSP.
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/. c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/.c
HOUSE SEWER
GAR. FIREWALL
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE __jCONST.
FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
OUND PLUMBINd/J71'UNDERGROUND
A.C. UNIT
COLL. AREA
B GRADE G
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
Ctj�FOUND. REINF. L _ 023'_ 01 (
AS (ROUGH) �/ �,GJ
t o
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$
_$
GR.
(jAyAL INSP.
VVVV
//LUMBER
I ffl`RAMING �� I�.
FINAL INSP.
V(ROOFING �— G( �—�/ (
/j�f u ���i�`j ��%
(/f/✓/ j [
4:j/l
REMARKS:
_—
VENTILATION���
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
6SULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL