12715 (CP)T,dy 4 sCPQ�rw
P.O. BOX 1504
Building
Address LA QUINTACCAL FORNIA 92253
Owner
Mailing BUILDING: TYPE CONST
Address 12 01;� r ; `is .i
A.P. Number
City Zip Tel.
rt, CJ 92260 Legal Description
Contractor
Pools
Address-.4ockingbird 'Frail
r
City Zip Tel.
State Lic. City.
& Classif_ A t — 50 tic. # � S'
Arcb., Engr.,
Designer
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
4, '7000) of.Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE 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) 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 penally of not more than five hundred dollars (S500).
❑ 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 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 properly who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ I 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. ❑ Certified copy is hereby furnished,
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(This section need not be completed if the permit is for one hundred dollars (S100) valuation
or less, )
I certify that in the performance of the 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. -r ±'
.,e Date Owner
` 'NOTICE TO APPLICANT., P. altar making this Carriflcare of Fxompfion you should become
subject to the Workers' Compensafton provlslohs of the Labor Coda, you must forthwith
comply with such provisions or Phis permit shell be deoMad 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 Nan?
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:
t agree to comply with all city and county ordinances and stale laws relating to building
construction, and hereby authorize represenfatives: of this city to enter the above•
mentioned property for lnspection purposes.
Signature of applicant Date
Mailing Address
City, State, Z€p
Description
No. J. 2 7r1.
OCC. GRP.
Sq. Ft, No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. D p.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
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 bv.
Validation: !_:
CONSTRUCTION ESTIMATE
NO.
ELECTRICAL FEES
NO.
PLUMBING FEES
1ST FL. SQ. FT. @
2ND FL. SQ. FT. @
POR. SQ. FT. @
GAR. SQ. FT. @
CAR P. SO. FT. @
WALL SQ. FT. @
SQ. FT. @
ESTIMATED CONSTRUCTION VALUATION
$
UNITS
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
$
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
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.
SQ. FT. RESID @ 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR @ 3/4c
HOUSE SEWER
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
3EWER OR SEPTIC TANK
ROUGH WIRING
niICT WORK
ROCKSTORAGE
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
W/—EINAL INSPy—`d v/
G
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECT 0 R' S Si0NR7U R ESII N ITFALS
GARDEN WALL FINAL