05520 (SFD)4
P.O. BOX 1504 N o .
48-1M5 Vista Cielo LA QUINTACCALIFORNIA 92253
Fil
ling
tress "10 Corbin AW- S.3
Northriege . zlp I .91324
imma C. C"1R
BUILDING: TYPE CONST. . OCC: GRP.
A.P. Number. - 617-640-055
ll. Le Lot 5S
gal Description
Project Description 11aM 2
77--200 141tiniesota
City Zip Te .
t '�a.3.tt-Deeert 922601 34 �-5G39
State Lic.. City
& Classif. B 195333 Lic. # 250
Arch., Engr.;
Designer
Address Tel
City Zip State
Lic. #
'LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I alicensed under f)rovisions of Chapter 9 (commencing with Section
7000) Division 3 of them Business and Professions Code, and my license is in - full force and
SIGNATURE / �' DATE
OWNER -BUILDER DECLARATION
�_ I hereby affirm that I am exempt from the Contractor's License Law for the following
masohK.(Sec. 7031.5,19usiness and Professions Code: Any city or county which requires a
Pamdf to construct. after, urprove, demolish, or repair any structure, prior to its issuance also
regimes 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
Divisor 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exenptian. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the appilicant to a civil penalty of not more than rive hundred dollars ($500).
❑ 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 Conbactor'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 iWrovements are not intended or offered for sale. • If, however, the building
orerprovement 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.)
❑ 1, 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
1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No mpa„ y '
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
` CERTIFICATE OF EXEMPTION FROM
j WORKERS' COMPENSATION INSURANCE
(//tis section need not be correlated if the permit is for one hundred dollars (8100) 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: fl, after making this Certificate of Exemption you should become
suhject to the Workers' compensation provisions of the Labor Code, you must forthwith
coney 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.)
Lenders Name
Lenders 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.
1 certity.that I have read this application and state that the above information is correct.
.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
05520
Sq. Ft. 2852 No. No. Dw.
Size Stories Units
Newt] .Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation $100,92840
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
a�tt
Const.
•3��
Mech.
•
Electrical
Plumbing
323• O
S.M.I.
Grading
Driveway Enc.
Infrastructure'
s �•�
r �-tcs'a
s t1
f
TOTAL
REMARKS - --- -:�.�- �.,.. n T
' �, w � "�r`'f'�ait'i s....`t. `�,i tyi.�" . ��, ..�� :7 , "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
3/14/89
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES -
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
2ND FL SQ. FT.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. SQ. Ff. ®
DUCT WORK
ROCK STORAGE
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEQUIP.
DRAINAGE PIPING
CAR P. SQ. FT.
TEMP. POLE
WALL SQ. FT.
GROUT
DRINKING FOUNTAIN.
SQ Fr. ®
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
=$
FLOOR DRAIN
MECHANICAL FEES
FRAMING y G
a �G
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
REMARKS:
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
IKITCHEN 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.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
MESH
SQ.FT.GAR @ 3/ac
HOUSE SEWER
INSULATIONISOUND
7
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 PLUMBIN
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF. y� �Q'
GAS (ROUGH) //
Z
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
INAL INSP. ``
FRAMING y G
a �G
FINAL INSP.
ROOFING ti
/J
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING 0ICV Y2 01
MESH
INSULATIONISOUND
7
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
'
GARDEN WALL FINAL