SFD (04604)`Y P.O. BOX 1504
Buildingr5.2-415 jsa,3it aro LA QUINOTACCAL CALIFORNIA 92253
Address
Owner
Sob MoZ1°1 oa &• Robert Jones n
'- BUILDING:' TYPE CONST. OCC. GRP.
A.P. Number
Address P. 0. BOX 921 - 77773-274-019City Zi
Rialto
p Tel.
92-7f -714-g7$-6000 Legal. Description
Contractor S * #D.
Bob Mo oe
Aaaress
515 W. Rialto Avon e
• City Zip Tel
Riaitf 92376 Si
State Lic. City
& Classif. 361079 Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) lot Division 3 of the Business and Professions Code, and my license is in full force and
effeclf• .'1 { r ,��.':.''�,."�,�++.,:..•. i�� %11 `4��
SLGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec... 7031.5,Buslness 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 for such permit to rile a signed statement that he is 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 thathe 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).
O 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 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,
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
or proving that he did not build or Improve for the purpose of sale.)
O 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.) -
O 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 certifled,copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
O Copy is filed with the city. O 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
Of less.)
1 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.
4 X04
Project Description
` , • rF- j
Sq. Ft. 1517 No. No. Dw.
Size. Stories Units
New ❑ Add O Alter O Repair O Demolition ❑
Plan Cheek fee will be f
tim pelt is pulled#
Aimated Valuation
h
PERMIT
Plan Chk. Dep.
Plan Chk. Bal
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL.
REMARKS
at
5s1F
AMOUNT
�iuU
105 X00
W i�x7
20.00
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) Side Setback from Property Line
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to FINAL DATEINNS/pECTOp�R
expiration if work thereunder Is suspended for 180 days. v p 340 8
I certify that I have read this application and state that the above Information Is correct. Issued by: Date Permit
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. Validated by:
Signature of applicant Date
Mailing Address Validation:
�r !• City, State, Zip•
1 WHITE. -. FINANCE, PINK -APPLICANT,. GREEN • BUILDING,:GOLOENftOD = •SSESSOR'S OFFICE, HARD COPY -FILE
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FE
ISI FL SO Fl (p =
UNITS
COLL. AREA
SLAB GRADE
ROUGH PLUMB
YARD SPKLR SYSTEM
2ND FL SO FT. a
HEATING (ROUGH)
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR SO FT. at
DUCT WORK
ROCK STORAGE
POWER OUTLET
ROOF DRAINS
GAR SO. FT. iiY
METER LOOP
HEATING (FINAL)
OTHER APP.IEOUIP.
DRAINAGE PIPING
CAR P. SO FT. *
0— f
TEMP. POLE
DRINKING FOUNTAIN
WALL SO. FT. Q
f
WATER HEATER
SERVICE
URINAL
SO. FT. (a
BOND BEAM
WATER SYSTEM
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
=$
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTONDISHI
APPLIANCE DRYER
,�/ `
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
VENTILATION
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.
SO. FT. c
BATH TUB
GAR. FIREWALL
SO. FT. rg c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID 11A c
SEWAGE DISPOSAL
SO.FT.GAR 1 c
HOUSE SEWER
INSULATIONISOUND
GAS PIPING
PERMIT FEE
FINISH GRADING
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 8 AIR COND. SOLAR
SETBACK
G 0UND PLUM BIN///,?,rPt
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.IEOUIP.
REINF. STEEL
(FINAL)3
&
0— f
TEMP. POLE
GROUT
f
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
E
GRADING
Cu. yd.
plus x$
=$
LUMBER GR.
FINAL INSP.
tw-RAMING
FINAL INSP.
R OFING / �' �O -
//
,�/ `
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR'
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
<A
INAL INSPECTION
CERT. OCC.
MEADOW LAND DEVELOPMENT CORP-.
" P.O. BOX 921
RIALTO, 'CALIFORNIA 92376
1
PAY TO THE
ORDER OF
16.4
1140 ,220
�. a'st
:�:� g �, 857• ��
All
----DOLLARS
Lie :� &UXMy, h1Zak/)1/ Security Pacific National Bank
FONTANA OFFICE 0913
8491 SIERRA AVENUE
FO NTANA. CALIFORNIA 82333
11200 111,011' 1: 12 200001.31: 3 L3-19? 2 S 711'