07133 (MFD5)4
P.O. BOX 1504 No. 07 133
Building77&105 CALLE ESTADO
Address -317 �>r}Lt ✓vOt1t" LA QUINTA, CALIFORNIA 92253
- - Boulevard Wvelopm rt
Mailing BUILDING: TYPE CONST. OCC: GRP.
Address 777 S. Main St.. Suite 106 613-790-013
A.P. Number
City Zip Tel. OLD #26 Unit X255
Orange CA 92685 Legal Description
Contractor Project Description P1�' 1
Safe
Tel.
State Lic. I City
& Classif.461814 Lic. #
Arch., Engr.,
Designer
Address Tel.
City IZip I State
#
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that,l am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and mylicense is in full force and
effect.! c c-�r:.,.-.+.-•
SIGNATLRE /' DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 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, demofsh, 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
the provisions of the Contractors License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Cade, 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 Man five 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, Suisness and
Professions Code: The Contnictor'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. ll, 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 safe.)
❑ I, 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 Durids or improves thereon, and who contracts for
such projects with a contractor(s) ficernsed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec_ R. & P -C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent'fo self -insure, or ace rfificate of
Worker's Compensation Insurance, ora certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company :
❑ Copy is filed with the city. ❑ Ceritied'copy-is hereby fumished. V
'� 1f
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed fir the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of ttV 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., ff, after rtnalurg this Certfioate of Exemption you should become
subject to the Workers' Compensation pvovisfons of Me labor Code, you must forthwith
comply with such provfsiom or this permit Shag 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. (Sac. 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 100 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
Sq. Ft. 926
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
range included
Estimated Valuation
jbbs .31
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
t 4 31
Const.
4V1.UU
Mech.
Z4. UU
Electrical
67. 56
Plumbing
0
S.M.I.
4. 1139
Grading
Driveway Enc.
Infrastructure
1,bU1,4b
TOTAL
REMARKSi�r.a,fA
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_INSPEC�00
Issued by: Date Permit
Validated by:
Validation.
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
UNITS
COLL AREA
SLAB GRADE �21
r��
YARD SPKLR SYSTEM
2ND FL. SO. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEOUIP.
DRAINAGE PIPING
CAR P. SO. FT. ®
GAS (FINAL)
TEMP. POLE
WALL SO. FT.
DRINKING FOUNTAIN
SO FT ®
WATER HEATER
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
REMARKS:
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.
SO. FT. RESID ® 1% 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 ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL AREA
SLAB GRADE �21
r��
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. eL
FRAMING `� L
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING lzaL%
MESH
INSULATION/SOUND ( a
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESJINITIALS
GARDEN WALL FINAL7d
1