0106-104 (SFD)JU
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I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and LDATEProfessionals Code, and my License is in full force and effect.
License* Lic. (lass Exp. Date
666895 B 04/30/21
OWNER -BUILDER DECLARATION
f hereby affirm under peru fly of perury that i am exempt from the Contractors
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, wig do the work, and the structure is not Intended or offered for
sale (Sec. 70K Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project {Sec. 7044, Business & Professionals
Code).
{) I am exempt.under.Sectlon. 131f,PC; for this reason
Date Signature of Owner
WORKER'S OOMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
{) I have and wiN maintain a certificate of consent to selfinsure for workers'
compensation, as provided for by Section 3700 of time Labor Code, for the
performance of the work for which this permit Is Issued.
( ) I have and will maintain workers' compensation Insurance, as required by
5ectlon 3700 of the Labor Code, for the performance of the work for which this
permit is Issued. My workers' compensation insurance carrier & policy no. are:
Carry Policy No.
STATE FUND 1576382-00
{Tire section need not be completed if the permit valuation Is for $100.00 or less).
( ) I certify that in the performance of the 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, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, t shall forthwith comply with those provisions.
Date: Applicant
tMaming: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addltion to the cost of compensation, damages as provided for in Section 378fi
of the Labor Code, Interest and attorney's fees.
for a permit subject to the conditions and restrictions set forth on his
applicalion.
1. Each person upon whose behalf this application Is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the Gfty of La Oulnta, Rs officers, agents and employees.
2. Any permll Issued as a result of this application becomes null and void if
work Is not commenced within 180 days from date of Issuance of such
oermit, or cessation of work for 160 days will subject permit to cancellation.
BUILDING PERMIT
VALUATION WT
794M FRESA ST.
RRM= HOWS
3400 CENTRAL AVMTUE OTE 325
R VER2JDR CA 92506
USE OF PERMIT
MHOLE FAMMY DWM. MG
PtHMI S a
010-104 TRACT
28490-7 I c`mo
APN F,
769-72x011 Al
SHEFFLUD HOh&B
3400 CENTRAL AVENUE i31'E 325
RIVERSIDE CA 92506
(909)682-5352 GBL# 5386
SHEFFIELD HOMES
3400 CENTRAL AVE
SPD_ -_LOT X.PLAN 3Co-DOMDOBS-WO. 1NCLUDE ftLOCK.WALT,.._._...__._.__.._..___
POOL OR DRIVEWAY APPROACH. 75%REDUCTION TO PLAN CHECK FEE
APPLIED FOR MULTIPLE SU8M.1T7AL OF SAME PLAN TYPE,
CUSTOM CONSTRUCTION 2,880D SF
PORCfVPAT10 324.00 SF
nARAOFICARPORT (ST) 10,584.00
ESTIMATED COST OF CONSTRUCTION
PERMrrIT14M SUMMARY
CONSTRUCT30N FEE
101-000.418-000
$1,129.50
PLAN CHECK FEE
101-000-439-318
$230.37
MECHANICAL FEE
101-000.421-000
$85.50
ELE►CTR.ICAL FLEE
101-000-420-000
8164.31
PLUM DINO FEE
101.000-419-000
3181.75
STRONO MOTION FEE - RESli3
101-OGO-241-000
$23.97
13RAD1NO FEE
101.000-423-000
$20,00
INFRASTRUCTURE FEE
225-000-443-342
$1,907.00
ART IN PUBLIC PLACES - RESIE 701-000-255-000
$99.28
SUB-'11C}TAL CONS t'RUCTIOW AND PLAN CHECK
LESS PRE -PAID FEES
TOTAL FIMr FEES DQE NOW
239,712.60
$3,841.68
$0.00
13,841.68
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