09153 (RER) 03
� IE
�----- � P.O. BOX 1504 No. 09153
Buildingr. 78-105 CALLE ESTADO
Address 44-46,P! Avila Drive LA QUINTA,CALIFORNIA 92253
Owner
r`a'n 'ere 01aary BUILDING: TYPE CONST. OCC:GRP.
Mailing
Address A.P. Number
City Zip Tel. -
Q3uf»tf 92253 564-4993 Legal Description
Contractor Project Description
era-to Conklin Cif mann Kitchen �rf�adel
Address AMgpyyyyV
111 47
City - Zip Tela
StJ"wtic" City
&Classif. Lic.# Sq. Ft. No. No. Dw.
B1 Size Stories Units
Arch., Engr.,
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition❑
Address Tel.
City Zip State
Lic.#
LICENSED CONTRACTOR'S DWLARATION
I hereby affirmmthgt I am licensed under pryyisions o Chapter 9(commencing with Section
7000)of DivPsion'3 of the B §loess a d° rofessions ode,and my license is in full force and
.SIGNATURE -"'*�-+""^ " C-.�/'- ' � `i DATE
OWNER-BUILDER DECLARATION Estimated Valuation
I hereby affirm that I am exempt from the Contractors License Law for the following r
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
peimit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also '
requires the applicant for such permit to file a signed statement that he is licensed pursuant to PERMIT AMOUNT
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 plan Chk. De '
for the alleged exemption. Any violation o/ Section 7031.5 by'any applicant for a permit p -
subjects the applicant to a civil penalty of not more than five hundred dollars($500). -Plan Chk• Bal.
❑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 Const.
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
or Improvement is sold within one year of completion, the owner-builder will have the burden Electrical
of proving that he did not build or improve for.the purpose of sale.) '
❑ 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.I.
such projects with a contractor(s)licensed pursuant to the Contractor's License Law.),
Grading
1 am exempt under Sec. B.&P.C.for this reason
Driveway Enc.
Date - owner Infrastructure
WORKERS'COMPENSATION DECLARATION
Ihereby 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
VISpy is filed with the city. ❑Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS'COMPENSATION INSURANCE
-(This section need not be completed If the.permit is for one hundred dollars ($100) valuation •_. .,r,.,,.,.,. :• K .: r--_ :' 'i
or less.) V
I certify that in the performance of the work for which this permit is issuedi 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
work for which this permit is issued.(Sec..3097,Civil Code.). Side Setback from Property Line
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.
I certify that I have read this application and state that the above information is correct.. Issued by: Date Permit
1 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
i. Mailing Address Validation:
i City, State, Zip
CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES
1ST FL. SO.FT.® $ UNITS
2ND FL. SO.FT.
YARD SPKLR SYSTEM
POR. SO.FT.® MOBILEHOME SVC. BAR SINK
GAR. SO.FT.® POWER OUTLET ROOF DRAINS
CAR P. SO.Ff.
DRAINAGE PIPING
WALL SO.FT.
DRINKING FOUNTAIN
SO.FT.® URINAL
ESTIMATED CONSTRUCTION VALUATION $ WAIER 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(AUTO)(DISH)
APPLIANCE DRYER GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY
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. SO.FT.RESID®11/.c SEWAGE DISPOSAL
SO.FT.GAR®3/.c 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& COND. SOLAR
SETBACK GROUND PLUMBING UNDERGROUND 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'90111
HEATING(FINAL) OTHER APPJEOUIP.
REINF.STEEL GAS(FINAL) TEYll.rPOLE
GROUT WATER HEATER SERVICE FINAL INSP.
BOND BEAM WATER SYSTEM
GRADING
LUMBER GR. FINAL INSP.a l �l /
cu.yd.
FRAMING _22-Ct/ �� FINAL INSP.
l $ plus x$ =g
ROOFING REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
f 1j
LAIHING 1 —;L —l.(LD
MESH (� h
INSULATION/SOUND
FINISH GRADING l
FINAL INSPECTION2`ljl aq
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL