002116 (SATT)P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 80-3.51 Oak TM LA QUINTA, CALIFORNIA 92253
Owner
BUILDING: TYPE CONST.
Mailing
Address 75—MS 000*Vy Club Dr -
City Zip Tel.
.. Palm pert .-92260 ' 1 569--2828
Contractor
ress .
Sam
State Lic. City
& Classif.. 298130 Lic. # 328
Arch.; Engr:,
Designer
Address Tel.
City Zip State
. • Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that Lam licensed under provisions of Chapter 9 (commencing with Section
70(X1) of Division,3 of the Business and Professions Code, and my license is in full force and
effect. V .f / _+�,
SIGNATURE 3It,-.f A, A/ .'41 " F DATE
` '«OWNER -BUILDER DECLARATION
I hereby affirm that I am exemptyfrom 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, after, 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 ($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 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 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; ora 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' 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 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'- Co...pensation
Laws of California.
"Date Owrier
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
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 it 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 �+•! ! w` Date
Mailing Address
City, State, Zip
t i
HARD COPY
No: 002116
OCC: GRP.:
A.P. Number
Legal Description
Project Description PM MW PW 3 0
DM 1627
Sq. Ft. (;L1k 424 No. 1 No. Dw. I
Size Stories Units
New Ot Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation .
d Rra�trr 'tcn
PERMIT
AMOUNT
r
Plan Chk. Dep.
250.00
Plan Chk. Bal.
U4019
Const.
443.59
Mech. .
34.00
Electrical
67.41
Plumbing
87.50
S.M.I.
7.18
Grading
Validated by:
Driveway Enc.
Infrastructure
_1,554.98
TOTAL
205.76 2,3()8.76
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:
A4565 3 6 231,& % 6 it
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE 6 y
2ND FL. SQ. FT.
30NDING
YARD SPKLR SYSTEM
POR. SQ. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
CARP. SQ. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SQ. FT.
OTHER APP./EQUIP.
DRINKING FOUNTAIN
SQ FT @
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT S ?� /
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP'COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
=1NAL 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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID @ 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SQ.FT.GAR Q 3/ac
HOUSE SEWER
LATHING S
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 G �/
f ROUND PLUMBING J/ g6
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE 6 y
kOUGH PLUMB. !
30NDING
HEATING (ROUGH)
STORAGE TANK
FORMS
ySEWER OR SEPTI y
f,I40UGH WIRING f/�y6
DUCT WORK
ROCK STORAGE
FOUND. REINF. �/y
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
REINF. STEEL f/Z 7�i
GAS (FINAL)
TEMP. POLE
GROUT S ?� /
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM !;/2, 7
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
=1NAL INSP.
FRAMING 4P "?�l
FINAL INSP.
ROOFING G�/
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING S
MESH
INSULATION/SOUND 5� S -
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
'
INSPECTOR'S SIGNATURESIINITIALS.
GARDEN WALL FINAL
ilk r