05017 (SFD)4
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 54-997 Riviera LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address
City lZip
Address ..... _ . �.... �,,.,.. . _
State Lic. City
& Classif. 268130 Lic. # 328
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 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.
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,Busi7ess 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 rule 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).
❑ 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 inproves 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
orimprovement 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-
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.)
❑ 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
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(ibis section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
1 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: t, 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 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
Lenders 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 certity 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
No. 05017
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number 2VI,
Legal Description
Project Description s►s ». 171
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Sq. Ft. 23,33
Size `
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
INSPECTOR
Issued by:
Date 12/ W /8 ermit
Validated by:
Validation:
Estimated Valuation
`170.378
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
$ 497.78
Const.
610.50
Mech.
39.00
Electrical
92.01
Plumbing
114.00
S.M.I.
11.94
Grading
Driveway Enc.
Infrastructure
$3.833.51
1,916.76
T.s.baa Credit
1.916.76
TOTAL
$3.281.99
-Z .'_'
REMARKS
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 12/ W /8 ermit
Validated by:
Validation:
53 CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® $
UNITS
VIO(B GRADE G 5
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEQUIP.
DRAINAGE PIPING
CAR P. SO. FT. ®
TEMP. POLE
i
WALL SQ. FT.
GROUT
DRINKING FOUNTAIN.
SO. FT. ®
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
MING 1
WATER SOFTENER
VENT SYSTEM FADE EVAP.COOL HOOD
SIGN
WASHER(AUTOXDISH)
APPLIANCE DRYER
REMARKS:
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
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. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
MESH
SQ.FT.GAR ® V4c
HOUSE SEWER
SH
NSULATION/SOUND /
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
S ACK
OUND PLUMBIN?5'�/74PUNDERGROUND
A.C. UNIT
COLL. AREA
VIO(B GRADE G 5
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FO/RMSW'SqVER
OR SEPT T
ROUGH WIRING
DUCT WORK
ROCK STORAGE
ND. RE NF.
(ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
i
GROUT
WATER HEATER
-AVICE �Q Z
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
CU. yd.
$ -plus-x$-=$
L MBER GR.
FINAL INSP.
MING 1
FINAL INSP.
REMARKS:
VENTILATION
FIRE ZONE ROOFING -
FIREPLACE
SPARK ARRESTOR
G . FIREWALL
THI G Z3
MESH
SH
NSULATION/SOUND /
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL