04563 (RR)?.:i'4 .s
P.O. BOX 1504
Building' 7&105 CALLE ESTADO
' Address .52 $85 obregion LA.QUINTA„CALIFORNIA 92253
Owner ` Sh
enard
Mailing, _-.
Address.. -C�isfe ti
City lZip r
Contractor
Address
P IZi92201� ITeI. 345-3° 51
State Lia I City
& Classif. 274921 Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
Lic. #
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. g / ,,ate ,.X/XFV
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 he 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 thathe 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 or not more than rive 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.)
O 1, 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.)
❑ 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 NoJCl- Al A- {� Company
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
BUILDING: TYPE CONST. OCC, GRP.
A.P. Number 773-314-020
Legal Description
Project Description
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ ' Alter ❑ Repair ❑ 'Demolition O
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
WORKERS' COMPENSATION INSURANCE
Plan Chk. Bal.
Const.
o
Mech.
or less.)
Electrical
Plumbing
S.M.I.
employ any parson in any manner so as to become subject to the Workers' Compensation
Grading
Driveway Enc.
Infrastructure
Date Owner .
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
ZONE:
BY:
subject to the Workers' Compensation provisions of the .Labor Code, you must forthwith
Minimum Setback
Distances:
TOTAL�.a
CERTIFICATE OF EXEMPTION FROM
REMARKS
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars (8100) valuation
�r��t� a�ecc aa ee u ?las^
�F. 05 ;( �i�1�.,t.�si u,rtgY,A11i�i A!9 -J Y `act' 1R
or less.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any parson 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
ZONE:
BY:
subject to the Workers' Compensation provisions of the .Labor Code, you must forthwith
Minimum Setback
Distances:
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Side Street Setback from Center Line
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.)
Side Setback from Property Line
Lender's Name
Lender's Address
FINAL DATE
INSPECTOR a
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.
1 certify that I have read this application and state that the above information is correct.
Issued by:
i
Date Permit
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.
Validated by:
Signature of applicant Date
Mailing Address
Validation:
City, 'State, Zip
r , WHITE FINANCE PINK APPLICANT GREEN BUILDING; GOLDENii00 ASSESSORS OFFICE HARD COPY -FILE
_.a _..'w. n.e r. L•.. _.. . . - ..r. .:..�.. ,.:. .. .. .:!Y. .-fi,. �.... a ..S_'': .. '. 1: -.^.. .R.... t-. �_ ,.....Y::.=!. .�_ wY..
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL SO FT ra $
UNITS
SLAB GRADE
'
-
Y
ARD SPKLR SYSTEM
2ND FL SO FT. @
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING -
MOBILEHOME SVC.
BAR SINK
POR SO FTa
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR SO. FT. FF
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. I SO FT. a
FINAL INSP.
WALL SO. FT. (d
WATER SYSTEM
DRINKING FOUNTAIN
GRADING
cu. yd.
$ plus x$
_$
URINAL
SO. FT. a
FINAL INSP.
FRAMING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT'SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
FIRE ZONE ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIREPLACE
LAUNDRYTRAY
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.
SO. FT. ® c
BATH TUB
SO. FT. g c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID 114 c
SEWAGE DISPOSAL
SO.FT.GAR&r V:c
HOUSE SEWER
FINAL INSPECTION
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.IEOUIP.
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
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL