04734 (PLBG) 29
l IE J 4
•t'
P.O. BOX 1504
Building '78-105 CALLE ESTADO
Address 49-ZI66 Avila LA QULNTA,CALIFORNIA 92253
Owner
Mailing
Me= , BUILDING: TYPE CONST. OCC.GRP.
Address Sam A.P. Number Golf list 0� as
City Zip Tel.
La Quints 92253 Legal Description
Contractor :, Project Description Sawa " Hook-up
Eeononftwer Service
Address
P. U. x 192
City, Zip Tel.
Palm Deser 92261 146-2793
State Lica City
&Classif. 480962 Lic.# 42 Sq.Ft. No. No�,'Dw.
Size' " " " " Stories' Units
Arch., Engr.,
Designer' New ❑ Add ❑ Alter ❑ Repair ❑ Demolition O
Address Tel.
City Zip State
Lic.#
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that Ilam 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. -� . �i-11,.ra� .a..��...: fyt ' ��kj�
_SIGNATURE �•• 9 DATE
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following Estimated Valuation ,
reason: (Sec:,703;/;,5;Bus'" and Pro/essfons Code: Any city or county which requires a 00 '
permit to constru8f; alfer,'Improve, demolish, or repair any structure, prior to its issuance also
requires the;applicanlor.such P._ to rile a signed statement that he is lcensed pursuant to PERMIT AMOUNT
the provisions of the;Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Dlvisfon 3 o/•The'Business and Prolessions Code, or that.he is exempt therefrom, and the basis
/or the alleged exemption. Any violation of Section 7037.5 by 'any applicant for a permit Plan Chk. Dep.
subjects the applfcantto a civil penalty of not more than live hundedollars(E500).
O I,as owner of the property,or my employees with wages as their sole compensation,will Plan Chk. Bal. rr��fry� rryi�!
do the work,and the structure is not intended or offered for sale.(Sec. 7044,Buisness and COr1St. ?eG tl ll
Professions Code: The Contractor's 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, Mech,
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 Electrical
o/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 con- Plumbing
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 S.M.1.
such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
Grading -
O 1 am exempt under Sec. B.&P.C.for this reason
Driveway Enc.
Date Owner Infrastructure
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
O Copy is filed with the city. O Certified copy is hereby furnished. `
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS'COMPENSATION INSURANCE a h
(This section need not be completed if the permit is for one hundred dollars (4100) valuation2hr,,
or less.)
1 certify that in the performance of thg 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: If, after making this Certificate of Exemption you should become ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances:
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
I-hereby affirm that there is a construction lending agency for the performance of the
W
ork for which this permit is issued.(Sec.3097,Civil Code.) Side Setback from Property Llne
Lender's Name _
Lender's Address FINAL DATE INSPECTOR=
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. Z 4F
1 certify that I have read this application and state that the above information is correct. Issued by: Date -Permit
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. Validated by:
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
WHITE-FINANCE,PINK-APPLICANT,GREEN-BUILDING.GOLDENROD-,ASSESSOR'S OFFICE,HARD COPY-FILE
CONSTRUCTION ESTIMATL NO. ELECTRICAL FEES NO. PLUMBING FEES
IST FL SO FT y $ UNITS
YARD SPKLR SYSTEM
2ND FL SO FT.q
POR SO FT.at MOBILEHOME SVC. BAR SINK
GAR SO.FT.ro POWER OUTLET ROOF DRAINS
CAR P. SO FT.ra DRAINAGE PIPING
WALL SO.FT.@ DRINKING FOUNTAIN
SO.FT.
URINAL
(&
ESTIMATED CONSTRUCTION VALUATION $ WATER PIPING
NOTE Not to be used as property tax valuation FLOOR DRAIN
MECHANICAL FEES WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASH ER(AUTOXDISH)
APPLIANCE DRYER 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,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.RESIO @ t V.c SEWAGE DISPOSAL
SO.FT.GAR re 3/4c 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 8 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 APP.IEOUIP.
REINF.STEEL GAS(FINAL) TEMP.POLE '
GROUT WATER HEATER SERVICE FINAL INSP.
BOND BEAM WATER SYSTEM
GRADING
LUMBER GR. FINAL INSP. cu.yd.
FRAMING FINAL INSP. $ plus x$ _$
ROOFING REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR-
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL