002235 (SFD)44
P.O. BOX 1504
Building 54- 958 ITMermss LA QUINOTAC
Address CALIFORNIA 92253
Owner
slinwim
Mailing
Address 75-005 00tMtrV CL.Ub Dr.
City Zip Tel.
4
. �- 92260 -2828-
: Contractor L _ +
Address .
No.. 002235
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
Legal Description
Project Description RM '4E° PT&q 20 M
Pham 7R
City
Zip
Tel.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center.Line
State Lic.
City
U43 2596
INSPECTOR
& Class if. 280130
Lic. # 328
Sq. Ft.i
�
No. No. Dw.
Validated by:
Size
StoriesUnits
Arch., Engr., . .. .. � ..
A5080
4 8 3594,45 LK
Designer
New :+ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Address
Tel.
City
Zip
State
Lic. # . .. _
LICENSED CONTRACTOR'S DECLARATION
• I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
T000).of Division 3.of the Business and Professions Code, and my license is in full force and
+
.. .effect. � \.fs.. �.-���:.ij:.' ��•�.1�'t_ �:._.if"�..� �/
SIGNATURE' s �i"er' .. ,,^' _. = DATE .
.. _
'OWNER -BUILDER DECLARATION
I he eby affirm that I am exempt fromthe Contractor's License Law for the following
Estimated Valuation
t
b
.reason: (Sec. 7031.5,ausiness and Professions Code: Any city or county which requires a
peimit to construct, atter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit toe lile 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 the alleged 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'dollars ($500). • -
Plan Chk Bal.,495.15
'
O I, as owner of the property, or my employees with wages as their sole compensation, will
dothework, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
- Professions Code: The
.
C60St.
�pp
Contractor'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,
Mech.
dap+Y�
55.00
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
Electrical -
-
1".06
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
132.50
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
S.M.I.+�Q
.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) -
-
Grading
❑ 1 a exempt under Sec. B. & P.C. for this reason
Driveway Enc.
Date , owner
Infrastructure
2,000+00
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.. ❑ Certified 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: 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. '
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 it work thereunder is suspended for 180 days.
I certify that 1 have read this application and state that the above information is correct.
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 for inspection purposes.
Signature of applicant x C��%. -'� f� ( � i!_-� Datel Yr � f'/'
Mailing Address.�'•�. !r yl 1
City, State, Zip 1 b'
HARD COPY
TOTAL 3.394.95
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
INSPECTOR
Issued by:
Date Permit
Validated by:
Validation:
A5080
4 8 3594,45 LK