002096 (PLBG)P.O. BOX 1504 No 002096
Building A��& � LA QUINOTACCALIFORNIA92253
Address -
Owner
Mailing
Address
CityZip Tel..
T _.92253_ .
Contractor
OMLIX,lde
3UILDING: TYPE CONST. OCC: GRP. -
4.P. Number .73-335-005
_egal Description Lct 22
3roject Description
Date Owner
NOTICE TO APPLICANT: 11, 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 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. yj
Signature of applicant NI -�!'zr •a _ .d`.�"✓vr _ Date
Mailing Address
City, Slate, Zip
HARD COPY
ZONE:
BY:
Minimum Setback Distances:
City
Zip
Tel..
Rear Setback from Rear Prop. Line
State Lia
& Classif.
City
Lic. #
Sq. Ft. No.
Size Stories
No. Dw.
Units
Arch., Engr.;
Designer
New (Ir Add ❑ Alter ❑:
Repair ❑ Demolition. ❑
Address
Tel.
Date - Permit
Validated by:
City
_. ..
Zip
State
Lic: #
A:4.477_._
Insta t = septic
system.
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. 703 1. 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 ffle'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 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 Me 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, Bulsness 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
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 law -
does not apply to an. owner of property who builds or improves (hereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ I am. exempt under Sec. B. 8 P.C. for this reason
Estimated Valuation
. .
PERMIT• AMOUNT
e�
Plan Chk. Dep.
-
Plari Chk. Bal.
COnst..
Mech.
,
, EI@CtrICBI' '
Plumbing
.
40.00
S.W.
Grading
Driveway Enc.
Date Owner
Infrastructure
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.
- -
TOTAL
MAU•U
REMARKS.
-
Date Owner
NOTICE TO APPLICANT: 11, 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 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. yj
Signature of applicant NI -�!'zr •a _ .d`.�"✓vr _ Date
Mailing Address
City, Slate, Zip
HARD COPY
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:
A:4.477_._
3. 3 4..000 Tl
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEESNO.
PLUMBING FEES
1ST FL. SQ. FT. ® $
2ND FL. SQ. FT. ®
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. I SQ. FT. @
WALL SO. FT. ®
SO. 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.COOL 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.
SO. FT. RESID @ 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR Q 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
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL :d