07163 (MFD5)Buildin
Address 78-263 Scarlet Court
Boulevard Revel
(f,i'tit 4 4 14"
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Mailin
Address 777 S. Main Street Suite 106
City Zip Tel.
Orange CA 1 92686 714-547-8056
Contractor
Address
State Lic. City
& Classif. 461814 Lic. #
Arch., Engr.,
Designer
Address I Tel.
City IZip I 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 of the Business and Professions Code, and my license is in full force and
effect..... _,+,a+u r , �,•-
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,Business and Professions Code: Any city or county which requires a
permit to construct, after, improve, demolish, or repair any structure, prior to is issuance also
requires the applicant for such permit to We a signed statement that he is licensed pursuant to
the provisions of the Contractors 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
tar the alleged exemption. Any violation or Section 7031.5 by 'any applicant for a permit
subjects the applicant to a etwl penalty of not more than five hundred dollars (8500).
of ,
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 Contractors 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 rat 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 inprove 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. 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 certifica&of
Worker's Compensation Insurance, ora berlified,copy thereof. (Sec: 3,800, Labor Code:) ,.
Policy No. Company \J.er
❑ Copy is filed with the city. ❑ Cepified copy is hereby furnished.
„1r•
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the pemrt 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 parson in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: ft, after mabV this Certificate of Exemption you should become
subJect to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions Of fink 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 it work thereunder is suspended for 180 days.
I certify that 1 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. 07153
BUILDING: TYPE CONST. • OCC: GRP.
A.P. Number 613-7904€312
Legal Description BLD #29 Unit f282
Project Description Plan 2L
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 2/21/9DPermit
Validated by:
Validation:
Sq. Ft. 912
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
$65,225
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
jib, 23
Const.
486,',i
Mech.
4,
Electrical
67.14
Plumbing..
S.M.I.
4.62
Grading
Driveway Enc.
Infrastructure
1,46T.57,
TOTAL
REMARKS
Xyl tats.°. YC
Y. FS.uaTiL s. �,J afu. lv
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 2/21/9DPermit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
YARD SPKLR SYSTEM
2ND FL SO. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
FOR. SO. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
DRAINAGE PIPING
CAR P. I SO. FT.
GAS (FINAL)
TEMP. POLE
WALL SO. FT.
DRINKING FOUNTAIN.
GROUT
WATER HEATER
URINAL
SO FT ®
FINAL INSP.
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
GRADING
cu. yd.
$ plus x$
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOXDISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
REMARKS:
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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 ® 11/4 c
SEWAGE DISPOSAL
SO.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 64 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. C B�Q ?
7
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 (,o
FRAMING
V
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
5 vi
HING G r
MESH
INSULATION/SOUND 3 �q
FINISH GRADING
FINAL INSPECTION
/21qt 18
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESlINITIALS
GARDEN WALL FINAL