12467 (SFD)WA
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address r ' = E ' :LA LA QUINTA, CALIFORNIA 92253
Owner
Mail- d
Address i; l 0 -i 1; . 7,1i--
City Zip Tel.
Contractor
Address
City ]Zip I Te
5tateLic. 395 City
& Classif. Lic. #
AtDes grl:
9er
Addre3ss ;T�t 4) a 41 _45 L `�
City Zip n _ State
Ana
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.
SAW4ATt1RE . - _ DA.
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 far such permit to file a fined statement that he is Ilcensad pursuant to
the previsions of the Contraclor.'s Llconse Law, Chapter 9 (commencing wrlh Section 7000; of
I7fvlslnn 3 of the Business and Ptalesslons Code, at Ihat he k exempi 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 penally of not more than five hundred dollars (S500).
❑ 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, Bussness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or .hipsoves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. It, 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.)
❑ 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 contractors) 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
O Copy Is filed with the city. J:Certifitd 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., 11, akef making this Caffr7lcafe of Exemplion you should become
subject to the Workers' Compensation provislans of the Lahoi Coda,. you must forthwith
comply with such provisions pr this pofmil 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 1 have read this application and state that the abova information 15 correct.
I agree to Comply with all city and county ordinances and state laws relating to building
consttur"on, and hereby authorize representatives of this city to enter the above-.
mentioned property for Inspectlon purposes.
Signature of applicant. Date
Mailing Address
City, State, Zip
No.
BUILDING: TYPE CONST: OCC. GRP.
r,r4..2»;,,__ 110
A.P. Number
12467
Legal Description r - �453j1� S 3
Project Description `'- r3 i A
Sq. Ft. No. No. Dw.
Size 1 %,° `t Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition G
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
S 31.. i 3
Mech.
i}
Electrical
i- 17. 30
Plumbing
i ! a , ;;d`}
S.M.I.
Grading;)
Driveway Enc.
, ii 0
Infrastructure
'. f,94 , 5
TOTAL
'a.
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
i
Issued by: Date Permit
� I LI . -
Validated by: I
I
Validation: i
�V
CONSTRUCTION ESTIMATE
NO.
ELECTRICAL FEES
NO.
PLUMBING FEES
1ST FL, SO. FT. ®
2ND FL. SQ. FT.
FOR. SQ. FT. ®
GAR. SQ. FT. ®
CAR P. SQ. FT. @
WALL SO. FT. ®
SQ. FT. g
ESTIMATED CONSTRUCTION VALUATION
$
UNITS
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
$
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
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 IfO3
GROUND PLUMBINGC y 7
A-U)+DMGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
GH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER
ROUGH WIRING
DUCTWORK
ROCKSTORAGE
FOUND. REINF. j� Q,j►'
id fl
GAS (ROUGH) ��?I:
— METER LOOP
HEATING (FINAL)
OTHER APP.IEQUIP.
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 / yr/
FINAL INSP.
ROOFING J !r G
7
%/ /!f
�/ lr �-
11
/ L
REMARKS-
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING -t' 0}'✓I(/
MESH
INSULATION/SOUND
FINISH GRADING
�+
FINAL INSPECTION ?1 arj fL
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURE57INITIRLS
GARDEN WALL FINAL
--
mu
of Iza taVtut�t
I t an *h
NS U t b t* U Y'llat totlan
PA Certlftdie issued pursuant to the requirements of Section 306 of the Uniform Building!
Code certifying that at the time, of issuance this structure, was In compliance with the various,
wdin'.dnces, of the City regulating building construction or use. For the following.-
BUILDING ADDRESS 78-835 West Harland
Single Family Dwelling12467
811019. Fere it. No. t i '
Type Construction ion Fire Zone Use Zone -SR
_
Acacia Construction 8141 R. Kaiser Blvd. #310
Oirner of i0liong :4on Address -
Anaheim, CA 92808:
city
Mark Harold
syl
March 25, 1994
Ovilding Official
4r POST 10 A 609MOOW PLAN