10035 (BLCK)• 4 4 "
P.O. BOX 1504
Building 50_075 thru 50--175 Doral SIVA 78-105,CAL ESTADRNIA92253
Address
Brock HoStles
Mailing
Address
City lZip
Contractor
NeW Division Malls
Address
1005 Nolidaey Dr.
a F' 1418/967-9765
State Lic. City
&Classif. 6138$8 Lic.# 1874
Arch., Engr.,
Designer
Address Tel.
City (Zip (State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7,000) of.Division 3 of the Business and Professions Code, and my license is in full force and
Ufa fact!
/ _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,Susiness 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 hes 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 rive hundred dollars ($500).
0 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, Busness and
Professions Code: The Contractor's License Law does not appy to an owner of property who
builds or Improves thereon and who does such work himself at through his own employees,
provided that such improvements are not intended or offered for safe. fl, however, the building
orimprovement is sold within one year of completion, the owner -budder will have the burden
of proving that he did not build or Improve for the purpose of sate.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to com.
struct the project. (Sec. 7044, Business and Professions Code: The Contractors 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. 8 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.. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed f1 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
1 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 lays 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
No. 10035
BUILDING: TYPE CONST. OCC: GRP.
,A.P. Number
,Legal Description
Project Description
xfi9P.*..o9x 400' of 61 block wall
2001 of '3}' block wall
Sq. Ft.
Size
No. No. Dw.
Stories Units
New 0 Add ❑
Alter ❑ ❑ Demolition ❑
%Repair
Estimated Valuation
1-3000.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
1 4 4 • U
Mech.
Electrical
Plumbing
S.M.I.
1 • 30
Grading
Driveway Enc.
Infrastructure
TOTAL
T4 -t )• _30
REMARKS
4 t^0lit. P,014114, ''�i44!+ i 1)�-
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
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
POR. SQ. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. Q. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SQ. FT.
OTHER APPJEQUIP.
DRINKING FOUNTAIN,
SQ FT ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT
WATER PIPING
NOTE: Not to be used as property lax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE,TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER. B.T.U.
SQ. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SO.FT.GAR ® V4c
HOUSE SEWER
LATHING
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 APPJEQUIP.
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
L INSPECTIO
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL