001780 (AMUS)CV
P.O. BOX 1504
BuildingW-200 AN, t R Vy2ta � LA QUINOTACCALIFORNIA 92253
Address
Owner
No: 001780
BUILDING: TYPE CONST. OCC: GRP.
Mailing
Address
JP.E�o &3s.. 1600 A.P„Num,ber -
City Zip Tel.
922n 564"3333 Legal, Description
Contractor
LM
Address .
sam
City ... Zip. Tel.`
t?
WaIdw, CUP.
Project Description
State Lic.
City
& Classif..
file._..
,Lic. #�,
Sq. Ft.'
Size '
No. No. Dw.
Stories Units
Arch.,'Engr., .
Designer. • _
New ❑ Add ❑
Alter ❑. Repair ❑, Demolition ❑
Address
Tel.
City
Zip
State
_
Lic: # ...
LICENSED CONTRACTOR'S DECLARATION
hereby affirm ttiat 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 imfull force and
effect /
�l.
_ SIGNATURE '” - - ' ' DATE
r 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 forrsuch permit to rile a signed statement that heis 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). ' - '. " •
. ❑ 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,. Buisness and
Professions Code: The Contractor's License Law does no! apply to an owner of.property who..
Estimated'Valuation
-PERMIT- •
,
+�• -
- - ca. ''AMOUNT
Plan Chk. Dep. =
-
Plan Chk. Bal.
_ 0665t:
.
Mech.
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. If; 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 improye. for the purpose of sale.),.
"Electrical
-
Plumbing
❑ 1, as owner of the property,.am exclusively contractingwith 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 orimproves thereon, and who contractsfor
•• such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
.0. I am exempt under Seca- B. & P.C. for -this reason
S.M.I.
Grading
20.00
Driveway Enc.
Date owner
Infrastructure
WORKERS' COMPENSATION DECLARATION
��
R a 2M.00
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
❑ Copy is filed with the city.. _ O Certified copy is hereby furnished.
TOTALi.�
_
CERTIFICATE OF EXEMPTION FROM
• WORKERS'. COMPENSATION INSURANCE
:REMARKS
'
(This section need not be completed if the permit is for one hundred dollars ($100) valuation .
• or less.) .. .. _ _ .. ...
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.
' 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. ' '
ZONE: BY `
- Minimum Setback Distances:.. - -
Front Setback.from Center Line
Rear Setback from Rear Prop.,Line
CONSTRUCTION LENDING AGENCY
I hereby affirieh'ttiat there'is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.) "
Side Street Setback from Center Line
Side Setback frOm.Pfoperty Line
Lender's Name
FINAL DATE
ISSUed by:
Validated by:
Validation:
A3109
INSPECTOR
4
Date+�l95 . Permit
'
11 6 820.00 CK
-
Lender's 'Address
This is a'building'permit when properly filled out, signed and'validated, and is subject to
expiration it work thereunder is suspended for 180 days.
. I certify.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- tb"enter the above-: .
mentioned property for inspection purposes.,p r yF f0 ,, 'I "
Signature of applicant:
Mailing Address"J-! "
City, State, Zip F
HARD COPY
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
2ND FL. SO. FT. ®
POR. SQ. FT. ®
GAR. SQ. FT. ®
CARP. SQ. FT. ®
WALL SQ. FT. ®
SQ. FT. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APP.IEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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
REMARKS:
VENTILATION
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 PLUMBING
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.
GAS (ROUGH)
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
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
I UM'J WUNA I UMt511Nl t 1ALJ
GARDEN WALL FINAL