BLCK (10531)P.O. BOX 1504
Building O
52-710 NAVARRO LA QUINTAC
Address CALIFORNIA 92253
jAN A. SHOLLESGERGER
Mailing
Address g 0 BOX 59
City Zip Tel.
LA QUI14TA 92253 564-1
Contractor
GENPRAL C019TRACT i-iGHT.
Address
P 0 BOX 59
City Zip Tel.:
State Lic.
& Classif. 524325
Arch., Engr.,
Designer
Address
City
No. 10531
11LDING: TYPE CONST. OCC: GRP.
P. Number t
Legal Description
Project Description RETAIVING WALL — 2' X 150'
City
Lic. # 1235 Sq. Ft. No. No. Dw.
Size - Stories Units
Tel.
Zip State
Lic. #
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 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 in full force and
effect.
SIGNATURE DATE -
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 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) o1
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 morethan 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 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.sals. 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 improve for the purpose of sale.)
❑ I, 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 L'aw
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
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 '
❑ Copy. is filed with the city. 0 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 mustforthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby 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 if work thereunder is suspended for 180 days.
I certify that I 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 Date
Mailing Address
City, State, Zip
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
.`Plan.ChK. Bal.
Const. $ 0
Mech.
Electrical
Plumbing
S.M:I.
Grading
Driveway Enc.
Infrastructure
TOTAL — 0 —
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:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® $
2ND FL. SQ. FT.
FOR. SQ. FT. ®
GAR. SQ. FT. ®
CAR P. 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
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
I
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
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1+/e c
SEWAGE DISPOSAL
=$
SQ.FT.GAR ® 3/ac
HOUSE SEWER
FRAMING
FINAL INSP.
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
t SMI FEE PLUMB. FEE
STRUCTURE Z/ 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
tv
SEWER OR SEPTIC TANK
ROUGH WIRING.
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
�1
1
v�
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
[
WATER SYSTEM
FINAL INSP.
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION %2
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL