09095 (PLBG)44
P.O. BOX 1504 No. 09095
Building 78-105 CALLE ESTADO
Address 54-066 Obrecron LA QUINTA, CALIFORNIA 92253 v
Owner
Mailing
.Tfov_ca Thacker BUILDING: TYPE CONST. OCC: GRP.
Address same A.P. Number
City Zip Tel.
La ouinta 92253 564 1986 Legal Description
Contractor Project Description Sewer Hook Un
ess
68365 Perez Road
Zip Tel
nAf r4f-v 41>714>w 174»7`ti
State Lic.I City
& Classif. �. ,,,,—. Lic. #
Arcn., tngr.,
Designer
Address Tel.
City Zip State
Lic. #
ebtafLICENSED CONTRACTOR'S DECLARATION
fr
im that I am licensed under provisions of Chapter 9 (commencing with Section
of )i.Ision 3 of the Business.,6gd Prpfesslons Code, and my license is in full force and
/ % 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 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).
O 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 contracfor(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, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
KL (36,py is filed with the city. O 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' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, afar 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.
1 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 Date
Mailing Address
City, State, Zip
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
30,00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
30.00 io
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
IST FL. SO. FT. ® $
2ND FL. SO. FT.
FOR. SO. FT. ®
GAR. SO. FT. ®
CAR P. SD. FT.
WALL SO. FT.
SO. FT. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
<-
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WA7ER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
STORAGE TANK
WATER SOFTENER
VENTSYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FOUND. REINF.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
HEATING (FINAL)
LAUNDRY TRAY
AIR HANDLING UNIT CFM
GAS (FINAL)
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.
SO. FT. ®c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1+/4 c
SEWAGE DISPOSAL
FRAMING
SO.FT.GAR ® 3/ac
HOUSE SEWER
ROOFING
f
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 APPJEOUIP.
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
f
REMARKS:
�/�/
V
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
}
f
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5 •� 1 J
,•,.,,ry-,T,,, { �. 'lr ^.�•.Fr,a�,•i� �rC,;•'�,,,,.,;e.'" ' 7 ; 1 ?� �
a :. $ j',J'"a` {`'•»" ` d "oi�`'''- Y?` {,- r,r> •+ -.
a �' i'-. n .... a }"R�}��{Y f.�"'e�'T•c a `f'� Vii"' 1,��1� ��� '£�'`� w.
�, ?• i} %" H � WATER DISTA
AC ELLA VALLEY I
CASH RECEIPL,DETAIL " , • ` `� w � i q t
Received From..'
Address:
,. 7
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Account No. Lots) 4 -' r�'Trac -
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Service Address`a Gi4 Code; 'lrK 3 IN
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Meters)
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O Backflow(s) °a', e . � `' �� ,"�: ��'*�� � •�•� �-,<
❑ House Lateral(g) R ? ° 510y
r F t i r�sA
'
11 Detector Check(s) < �� tia7� r ` "� " <rS
❑MeterSurchar � _ a v'�a` "3X ti ; ` _ � ' •.�, ;--. � +<= �� r..�'
f 7 xf •- i zr '� r :�
Sanitation Capacity Charge
' - ,.--,�s-....- .i. � , nC,�l r,,.•r }s y�••y ey�,�•� , ,�5� ..rte-yT,
0, Temporary Construction Meter
❑ Turn on Charge-
❑ Uncollected Account - Name ;
❑ InspectionFee-Tract-
Fee -
❑ Plan Check Fees Water 1 Sewer
i' Tract
❑ Bond Payment - A.D. - $ond
' Assmt� r ..,.1 •n is, ca i.4 Q s ylj^ - i,' w ,.
-0 Customer Deposit
❑••Other �''•`-tE' - � - <� wit r � � � 4� r �
+TOTAL `„
Remarks:'
x
0 COPY to:
?..-fWaterServi '
Check
Money Ar
ash er f x !
r • Order,.
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