002148 (SATT)44
P.O. BOX 1504 NO. 002148
Building 8�fi31 0k � LA QUINOTA CAL CALIFORNIA 92253
. Address
Owner
s3Y2X iw ra 0211t}a
Mailing
Address 75-005 C=ntry Club Dr.
City Zip Tel.
pain Deswt 93260 568-2'1$26
Contractor
Address .
Sam
City Zip Tela '
Sam
State Lic. City
& Classif. 2813130 Lic. #
Arch., Engr., '
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'$,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.. � �. 'i! s's,v. ^.' ; J`� rJ"•
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 rile a signed statement that he -is licensed pursuant to
the provisions of the Contractor's "Ucense 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 fora permit
• ' subjects the applicant to a civil penalty'of not more than five hundred dollars ($500).' .
0 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'anowner 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.) '
0 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.)
0.1 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
0 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 ($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 Owrier-
NOTICE TO APPLICANT: If, alter 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.
Signature of applicant \ f �/fi. J /'i f r Date- I` 41- t
Mailing Address Y f - •j -'r �-
City, State, Zip
i
HARD COPY
JILDING: TYPE CONST. OCC: GRP.
P. Number
!gal Description
oject Description PGA 6a= PLAN 3 0 R
D" 3W-1
Sq. Ft. GAR 424 No. 1 No. Dw. 2
Size -Stories Units
New ,J Add ❑ Alter ❑ Repair ❑ Demolition O
Estimated Valuation
PERMIT
r
AMOUNT
Plan Chlf. Dep.
Plan Chk. Bal.
364.19
Const.
443_50
Mech.,
34.00
Electrical
67_41
Plumbing
87.50
S.M.I.•
7119
Grading
Driveway Enc.
Validation:
Infrastructure„
554;yQ
A4657
3 10 255.&76 Sl --
TOTAL
2.558.76
REMARKS
tt
OM AM �.; 1.
y��.� �wtye�p
FxA. I.>t .0 4ai [T..i 1 q iCi;.".
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:
A4657
3 10 255.&76 Sl --
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEQN,
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. SQ. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SQ. FT.
OTHER APP./EQUIP..
DRINKING FOUNTAIN
SO. FT. ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT
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
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
LATHING CJ ZL
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
`"' ROUND PLUMBING 7 �//
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE / �/
OUGH PLUMB. /
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
ER OR SEROUGH
WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF. i
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP..
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 /� �V `,dg
FINAL INSP.
ROOFING G
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING CJ ZL
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL