11951 (BLCK)• P.O. BOX 1504
Buildin78-105Addrress 54-190 Obregon LA QUINTACCALIFORNIA 92253 -
• Owner
Hank Czeransk5
Mailing BUILDING: -TYPE CONST. OCC: GRP.
Address 67--220 Rango Rd.
A.P. Number
City; ZiP
Cathedral City 92234 _ 322--8085 Legal Description
Contractor1201 of 61" high -block wall.
Han Czerah.ski Construction'Project Description
Address
City
`:State Lic. 5(32905 City 2083
& Classif. Lic. #
'Arch., 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
-7000) of Division 3 ofthe Business and.Brrofessions Code, and my It n'sels in full force and
effect. �%`7�T•r'
SIGNATURE ._•wry' - - DATE ,
OWNER -BUILDER DECLARATION t
` I hereby affirm that I am exempt from the Contractor's 'License Law for the follovwing
'reason: (Sec. 7031.5,Business and Professions' Code: Any city' or J 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 (commencingwith Section. x7000) 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 ilie applicant to a civil penalty of not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation, will
tdo 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.) -
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con-
i 'structithe,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
�jauch projects with a contractor(s) licensed pursuant to the Contractor's License Law.) -
iI 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.)
P1, .Company +
opy 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 manners a to becom subject,to the Workers' Compensa ibn
/jLaws of California. t
Date Owner
NOTICE TO APPLICANT: If, ra'ftFr 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
Ihereby 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 Date
Mailing Address
City, State, Zip
i
Sq. Ft. "No.,�w•
Sizer' _ _ r s 1. Stories.
New ❑' Add.❑ Alter ❑
No. Dwr+
Units
Repair ❑ --Demolition ❑
Ir -
PERMIT
Plan Chk. Dep. -
Plan Chk. Bal.
Const.
Mech.
Electrical ,
Plumbing
.S.M.I.
Grading
Driveway Enc.
Infrastructure
+ AMOUNT
q:y =
s'-
r TOTAL
REMARKS
� �'l�r�'�`�.s�,.%�1�',.�h��.;'FiwS",��"'�?Z 4-_5r.�r•.'�,li-;
- - R
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:
STRUCTURE — PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK .12 Lyl
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
BONDING
1ST FL. SO. FT. ® $
UNITS
-FORMS
SEWER OR SEPTIC TANK
2ND FL. SQ. FT.
DUCT WORK
YARD SPKLR SYSTEM
FOUND. REINF.
GAS (ROUGH)
MOBILEHOME SVC.
BAR SINK
OTHER APPJEOUIP.
FOR. SQ. FT. ®
GAS (FINAL)
TEMP. POLE
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
SERVICE
FINAL INSP.
DRAINAGE PIPING
WATER SYSTEM
CAR P. SQ. FT.
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
WALL SQ. FT. ®
FINAL INSP.
DRINKING FOUNTAIN
FINAL INSP.
SO. FT. ®
ROOFING
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
FIRE ZONE ROOFING
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
SPARK ARRESTOR
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LATHING
LAUNDRYTRAY
AIR HANDLING UNIT CFM
IKITCHEN 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
FENCE FINAL
SQ. FT. ® c
WATER HEATER
'
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR @ 3/ac
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 .12 Lyl
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADEAV
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
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL