05397 (ELEC)T414t 4 4 Q"
P.O. BOX 1504
Building-�:/ �P±i LA QUINTA8-105 C
AddressCAL CALIFORNIA 92253
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Lic. #
Arch., Engr.,
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LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
=of Division 3 of the Business and Professions Code, and my license is in full force and
SIGNATURE -s r..' - -'.-• r y DATE
OWNEWBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason_ (Sec. 7031.5,Business and Profession Code: Any city or county which requires a
permit to construct, after, improve, demolish. or repair any structure, prior to its issuance also
requires the applicant for such permit to fie a signed statement that he is licensed pursuant to
Me provisions or the Contractor's License Law, Crier 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 or not more than five hundred dollars ($500).
D 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 Contractorls License Law does not apply to an owner of property who
bulls or improves thereon and who does such war* himself or through his own employees,
provided that such improvements are not intended or offered for salell, however, the building
OF improvement is sold within one year of completion, the owner -bunter will have the burden
of proving that he did not build or improve for the purpose of sale.)
O I, as owner of the property, am exclusively contracting with licensed contractors to com.
struct the project. (Sec. 7044, Business and Professions Code., The Contractor's License Law
does not apply to an owner or property who builds or irproves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. w, & 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
❑ Copy is filed with the city. 0 Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the pemd 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
alifornia.DateOwner
NOTICE TO APPLICANT: ff, after making this Cetifiicele of Exemption you should become
subfect to the Workers' Corrpensatrn provisions of the Labe Code, you must forthwith
coney with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 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.)
Lenders Name
Lender's Address
This is a building permit when property filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
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
No. 05397
BUILDING: TYPE CONST?. OCC: GRP.
A.P. Number 441"r;_!_-_7_11");4/"_/_ 5!= r ! ^^C
Legal Description
Project Description . '+✓�'- '��
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
-'
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
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 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. gp, FT_ ®
DUCT WORK
ROCK STORAGE
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEQUIP.
DRAINAGE PIPING
CAR P. I SQ. FT.
TEMP. POLE
WALL SQ. FT.
GROUT
DRINKING FOUNTAIN.
FT ®
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOXDISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
VENTILATION
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.
SQ. FT. ® c
BATH TUB
GAR. FIREWALL
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1 Ya c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
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
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 APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
WRVICE
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
F ISH GRADING
�VINAL INSPECTION
CERT. OCC.
FENCE FINA
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL