13179 (BLCK)P.O. BOX 1504 No.
Building 54-190 Obregon 78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
0
iffanenrl-, czeraln'ski
Mailing
Address 67-220 Raugo Road
City Zip ITel. -
Cathedral Citlif CA 92-2341.- 322-8085
Contractor
Hank Czeranski const=&bAon-
Address
Sam
City Zip Tel.:
State L' City
S;1C- -"502905
&CIa if.,', - Lic. # 2081
�Arch.j En r.,,,,
Desigrfrer
Address. Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licenseq under provisions of Chapter 9 (commencing with Section
J7000) of Division 3,otifhe Business and �rofessions Code, and my license is ifffull force and
effect.
SLGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby'�ffirm that I am exempt from the Contractor's License Law for the following.
reason: (Sec. � 7031.5,Business and Professions Code: Any city, or i county. which requires a
permit to construct, alter, improve, demolish, or repair any structure, I 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 civilpenafty ofnot more than five hundred dollars ($500).
o I, as o�vner oi'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 io�i-Jmproves thereon and who does such work himself or through his own employees,
1ir6Wa6djthat' such, improvements are not intended or offered for sale. If, however, the building
lor�—iffi�ibviiment is sold within one year of completion, the owner -builder will have the burden
that he did not build or improve for the purpose of sale.) .
r1i wi;nler of the property, am exclusively contracting with licensed contractorsto 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
�uch 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 h�reby 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. 0 Certified copy is hereby furnished.
o
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed IT the permit is for one hundred dollars (S100) valuation
or less.)
I certify that in the performance of thq. work for which this permit is issued, I shall not
employ any person in any manner so asAb become sdbject.to4he Workers' Compensationj
Pws of California.
—Pate—owner
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 = afftirm that there is a construction lending agency for the performance of the
work ch his 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 car tify 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 applicanl� Date
Mailing Address
City, State, Zip
BUILDING: TYPE CONST. — . OCC� GRP
A.P. Number
Legal Description
Project Description . 25".0t 4' high block Walk,
Sq. Ft.
Size Stories
New 0 Add El.- " -41ter El
A
No. Dw.,
Units
Repair 0 ..Demolitio"n" 0
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback f.rom Rear Prop. Line
Side Street Setback from Center Line
—Side Setback from Property Line
,Estimated Valuation
$458.00
Issued by:
PERMIT
Validated by:
A�O'LINT�
Plan Chk. Dep.
Validation:
Plan Chk. Bal.
Const.
15.00
Mech.
Electrical
Plumbing
S.M. 1.
Grading
Driveway Enc.
/QX I 1 11
fill 'I Ina .
Infrastructure
By
TOTAL
REMARKS
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback f.rom Rear Prop. Line
Side Street Setback from Center Line
—Side Setback from Property Line
FINAL DATE
—INSPECTOR
Issued by:
Date—Permil
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEE6
1ST FL. SQ. FT. @ $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT. @
FORMS
SEWER OR SEPTIC.TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
FOR. SO. FT. @
GAS(ROUGH)
METER LOOP
GAR. SO. FT. @
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO. FT. @
GROUT
WATER HEATER
WALL SQ. FT. @
FINAL INSP.
DRINKING FOUNTAIN
SO. FT. @
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
I FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DIS H)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
VENTILATION
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET;
COMPRESSOR HP
POLE, TEMIPERM
ILAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. @ c
BATH TUB
LATHING
SQ. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR @ 3/4c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
I
MICRO FEE
I
MECH.FEE PL.CK.FEE
CONST. FEE ELECT.FEE
I I
SMIFEE FEE
I EPLUMB
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
ROCKSTORAGE
FOUND. REINF..'Z
GAS(ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEE
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
I 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 -7
CERT. OCC.
FENCE FINAL
INSPECTOR'SSIGNATURESIINITIALS
GARDEN WALL FINAL
r