BLCK (11-0440) + RPL (06205)44120 Mariposa Ct
11-0440
06205
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA
Applicant:
ZPOSA CT/Q bitX r
TY -R-ESIDENTIAL
Architect or Engineer:
alp
------------------
LICENSED CONTRACTOR'S DECLARATION
44
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
License `ss: C29 License No.: 804168
% ntractor:
/ OWNER -BU L•DERN
I hereby affirm under penalty of perjury that I am exam from the Contractor's State License Law for the
following reason (Sec. 7031.5. Business and Professions Code: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the -
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he or she 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 than 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,. Business and Professions Code: The
Contractors' State License Law does not apply to an owner of 'property who builds or improves thereon,
and who does the work himself or herself through his or her own employees, provided that the •
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 of proving that he or she did not build or
improve for the purpose of sale.).
1 _ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractorls) licensed
pursuant to the Contractors' State License Law.).
( 1 I am exempt under Sec. , B.&P.C. for this reason
Date: Owner:
CONSTRUCTION LENDING AGENCY _
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name: _
Lender's Address:
LQPERMIT
Owner:
'.DOEBEREINER PAUL H
44120 MARIPOSA COURT
LA QUINTA, CA 92253
Contractor:
AA MASONRY
77530 DELAWARE PL
PALM DESERT, CA 92211
(760)360-7388
Lic. No.: 804168
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
,Date: 5/02/11
-----------------------------------------------
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
for by Section 3700of the Labor Code, for the performance of the work for which this permit is
issued.
1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued. My workers' compensation
insurance carrier and _policy number are:
Carrier ARCH INS Policy Number 03DKRM12003
I 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,
and agree that, if I should become subject to the workers' compensation provisions of Section
3700 of the Labor Code, I shall forthwi h co ply with those/rov/visions.
ate: '
/Ap ant•
WARNI E TO SECURE WORKE COMPENS TIO OVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL P -NA _TIES AND13-Wil FINES UP TO ONE NDRED THOUSAND
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, -DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person at whose request and for
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is not commenced
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
permit to cancellation.
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 county too enter upon the above-mentioned property for inspection pt pose
ta. // S' ature (Applicant or Agent)'
C- .,, 'I v -)
Application Number:
11-00
Property Address:
44120-`
APN: •
604 -091 -
Application description:
WALL/FEN
Property Zoning:
LOW DENS
Application valuation:
15
Applicant:
ZPOSA CT/Q bitX r
TY -R-ESIDENTIAL
Architect or Engineer:
alp
------------------
LICENSED CONTRACTOR'S DECLARATION
44
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
License `ss: C29 License No.: 804168
% ntractor:
/ OWNER -BU L•DERN
I hereby affirm under penalty of perjury that I am exam from the Contractor's State License Law for the
following reason (Sec. 7031.5. Business and Professions Code: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the -
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he or she 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 than 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,. Business and Professions Code: The
Contractors' State License Law does not apply to an owner of 'property who builds or improves thereon,
and who does the work himself or herself through his or her own employees, provided that the •
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 of proving that he or she did not build or
improve for the purpose of sale.).
1 _ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractorls) licensed
pursuant to the Contractors' State License Law.).
( 1 I am exempt under Sec. , B.&P.C. for this reason
Date: Owner:
CONSTRUCTION LENDING AGENCY _
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name: _
Lender's Address:
LQPERMIT
Owner:
'.DOEBEREINER PAUL H
44120 MARIPOSA COURT
LA QUINTA, CA 92253
Contractor:
AA MASONRY
77530 DELAWARE PL
PALM DESERT, CA 92211
(760)360-7388
Lic. No.: 804168
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
,Date: 5/02/11
-----------------------------------------------
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
for by Section 3700of the Labor Code, for the performance of the work for which this permit is
issued.
1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued. My workers' compensation
insurance carrier and _policy number are:
Carrier ARCH INS Policy Number 03DKRM12003
I 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,
and agree that, if I should become subject to the workers' compensation provisions of Section
3700 of the Labor Code, I shall forthwi h co ply with those/rov/visions.
ate: '
/Ap ant•
WARNI E TO SECURE WORKE COMPENS TIO OVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL P -NA _TIES AND13-Wil FINES UP TO ONE NDRED THOUSAND
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, -DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person at whose request and for
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is not commenced
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
permit to cancellation.
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 county too enter upon the above-mentioned property for inspection pt pose
ta. // S' ature (Applicant or Agent)'
LQPERMIT _ -
Application Number . . . . . 11-00000440
Permit . . . .WALL/FENCE PERMIT
Additional desc .
Permit Fee 35.00 Plan Check Fee
00
Issue Date . . . Valuation .
. 1500
Expiration Date 10/29/17.
Qty Unit Charge Per
Extension
BASE FEE
15.00
10.00 2.0000 HND BLDG 501-2,000
20.00
----------------------------------------------------------------------------
Special Notes and Comments
60 L.F. 6' BLOCK WALL AT SIDE P/L, ORCO
SYSTEM. 2010 CODES.
---------------------------------------------------------------------------
Other Fees . . . . . . BLDG STDS ADMIN.(SB1473)
1.00
Fee summary Charged Paid Credited
Due
Permit Fee Total 35.00 .00 .00
35.00
Plan Check Total .00 .00 .00
.00
Other Fee Total 1.00 .00 .00
1.00
Grand.Total 36.00 .00 .00
36.00
LQPERMIT _ -
CITY OF LAQUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATES' Z -II BY
f
♦
i
i
P
ORCO STANDARD 6' TO 8' CMU SITE WALL
OPTIONAL RAT CAP DESIGN OUTERTA: PER THE2007 CSC
L ALLOWASLESOIL BEARING PRESSURE a 1500 PSF
Z ALLOWABLEWERAL PASS[VE PRESSURE -150 PCF
3. GROUTSTREJVGIH =1000 PST @ 28 DAYS.
4. R0NF0RQNGSTEEL : GRADE 60.
S.1500 PW MASONRY CiOMPREMON57RENGM
6816, 6616, OR 6618 i7MU
GROUTED ONLY Cal VL!RT NOTES'
STEEL
L CONCRETE SLOLTC SMLL CONFORM TO ASTM C 910.
Z CONCRETEFORWD77NGSHALL BEI PART CEMENT TO 2-112
Y'OROA•IN BAR PARTS SAND TO 3-1/1 PAR75 GRAVEL WIMA MAXIMUM OF 1-112
GALLONS OF WATER PER S4CX. PORTLAND CEN0T SHALL Ct7NFORM
TO ASTM 0150 TYPEZW Fc = 2500 PSI °
#6 STDJOlNT 3. RENTOR CINGSTEEL SHALL BE DEFORMIDAND CtWFORM TO
RQNFORCIMENT @ 24 OIC AS7NA 615 GRADE 6a PROWDE48 84R DIAMETER LM.
Z (3 PLACES- 4 PLACP> FORT
I & 8' WALLSt USE 09; STD. 4. REBAR SHALL BECEVTERED IN THECONOZETEBLOCX CELL IJV
FOR SLUMP BLOCK WMICHITISLOCATED.
5. C17NOWE NDMSHALL SE LAYER INA RUNIUNG BOND
PATTERN WITH VER77CAL CON77NU17YOFTHE CEZLS UNO.
NOTE: PRDVIDEBW DOIiYEZ @
P4 DROP-AV 84R AT EAi9f 6. ALL BLOCK CELLS CONTA0VING VER77CAL RE64R SHALL BESOLID
SDEOFCONTROLJOIII.IIS, GROUTED.
ENDS OF WALLSAND 6P WALL
Q HETGHrCH4NGE5 _ 7. USE TYPES MORTAR PROPORTIONED USTNGASTM C270 PART
CEMENT 7171/1 PARTLIMET04-112 PARTS DAMP, LOOSESAND.
C & GROUTFORCOAXNETEBI000PERASTMC47670BEI PART
CEMEM 703 PAR75SWD (GROUT MAY CONTATNI PARTS3/8"
PEA GRAVEL 1F WEATHER CONDMONSAREFAVORABLEAND BLOCK
A"DOWEL @ CEMER' OF UNOBSTRUCTED CP1L suEISSUF}TCTENT TO ALLOW GOOD LOUT.
CJMU fLOK9. WATER SHALL BEADDED 717 PRODUCE GOOD GROUT FLDW
WITROUT•SEGRErA77ON OF MECOWTUFNT'.
9. BLOCKSTEMM4YBE WET-SET 1-1/2- NTD THEF007ING WHILE
2 THE CONCRETE ISPLAS77C: BIDQCS7EM MAY HEP(AaW 7D
LEVEL GRADE BOTH:!JDES ET1'HEREDGE OFTHE 7RENCHTYPE FUMNG.
la FOOTING MLLST BE POURED ON OR IMO UNDISTURBED
NATURAL SOIL OR ON COMPACTED FILL WITH A MINIMUM
COMPACTION OF-W %..
#4 HOW CWi?: 1L FASTINSAEC770N TO WAFTER ManNG TRENCNESARE
READY FOR LIONLRE7FANDALL REQUIRED STEEL IS 77ED IN PLACE
SECOND INSPEC7ION TO HE WHEN 771E REQUIRED VERT=JS IN
fff PLACEAND THE BLOCK WALL IS READY 7O GROUT.
IZ MAXIMUM CONTROL ,JOWSPAC M. 40'0/C 20'01C FOR
WALLS T17 BEMORTAR WASHED OR STUCCO COA7EV
'W' CONT. F0077NG
SEE CART FOR REQUIRED REEiAR
AND FOOTING DIMENSIONS. a Ro F E S S, 0Nq
S.ui
m
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OF GA 25 m
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CHART FOR 6' TO 8' 511 TE WALL W/ SPREAD FOOTING
WIND
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WALL
SPREAD
'X' DOWEL
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SPEED
HEIGHT
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WIDTH
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Bin #
Oty of La Quinta .
Building 8z Safety Division
Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #P.O.
Project Address: • 7 — /20
C`
Owner's Name:
A. P. Number:.
Address: f 0 •
Legal Description:
Contractor: S _.l
City; ST, Zip: r
Telephone :'•.<+# z;;:.::;;:::::<::z:;:.;'>>::a
4k:i$:6:L:S•: {:j;:j'i.}iyiiiiii
:>:::s:<
' .
Address:Project
Description: 42V
City, ST, Zip:
C49.- R I
O
Telephone X-0 —z-(4 0 ' 7 F .
? :::; .<.:> ::»%>::::<.»> :<: ; ;:r •> ::>:::::.>.::.
i
State Lic. # : 9017,(Z -53
City Lie. #•:
Arch., Engr., Designer:
Address:
City., ST, Zip:
Telephone:
«' •>':•:?;<:>;::;:•>>>.>;:>:;::;,;<>::.t::.:.
.ri0••:>:yr>^.%.<rYviYh:%::iiiL>.>.:ii:Si:}>.:.:
<#:?:<:•':><:»::>:::>:'>:'?:' :::';;:a;x ts:
Construction Type; yp Occupancy:
State Lie. #:
project type (circle one): New Add'n Alter Repair
Demo
Name of Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Tide 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
god Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:
3 d Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
Building
Address 44-120
Owner
Rice
Address S
T4'y4 4 Q"
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
City I Zip Tel.
La Quiata 92253 1-345-6819
Contractor
75.5 Martinique
Gity Zip Tela
e da Dunes 92201 345-5070
State Lic. City
& Classif. 476807 1 Lic. # 134
Designer
Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Divisiom3 oY1fie'Business and Professions Code and m' license is in fulLforce`and-
effect. e . /
SIGNATURE DATE
OWNER -BUILDER DECLARATION '
1 hereby affirm that I am exempt from the Contractoes 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 its 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
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a ting penally of not mora than 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, Buisness and
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,
provided that such Improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of corrpfetian, 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 torr
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) 8censedpursuant 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 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. pany
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(This section need not be completed ff the permit is for one hundred dollars ($100) valuation
or less.)
I 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
NOTICE TO APPLICANT: fl, after making this Certificate of Exemption you should become
subject to the Workers' compensation provisions of One Labor Code, you must forthwith
comply with such provisions Or this permit shalt 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 if work thereunder is suspended for 180 days.
I certily 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. 06205
11LDING: TYPE CONST. OCC: GRP.
P. Number Cactus I lover
Legal Description
Project Description P001 ,6 SPA
Sq. Ft.
Size
No. No. Dw.
Stories A Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
93.6€
Const.
144.00
Mech.
30.00
Electrical
27.44
Plumbing
214.00
S.M.I.
1
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
sti1•:51 7 i,it. ' ia{ .i'1€ 7 Si cr, e, i }
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
8/23/89
Issued by: Date Permit
Validated by:
—Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
ROUGH PLUMB q/,t"f � BONDING
HEATING (ROUGH)
STORAGE TANK
YARD SPKLR SYSTEM
2ND FL. SO. FT.
DUCT WORK
ROCK STORAGE
FOUND. REINF.
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
REINF. STEEL
GAS (FINAL) TEMP. POLE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
WATER HEATER SERVICE
FINAL INSP.
DRAINAGE PIPING
CAR P. SO. FT.
WATER SYSTEM
GRADING
Cu. yd.
$ plus x$
WALL SO. FT.
LUMBER GR.
DRINKING FOUNTAIN-
OUNTAIN.SQ
SO.FT ®
FINAL INSP.
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
WASHER(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 ® 1% c
SEWAGE DISPOSAL
FINAL INSPECTION
SQ.FT.GAR ® VLc
HOUSE SEWER
CERT. OCC.
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 q/,t"f � 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.
FRAMING
FINAL INSP.
ROOFING
J/>'� d' �� �l/L 74_1
REMARKS:
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
P.O. BOX 1504
Building 78-105 C
LA QUINTACAL CALIFORNIA 92253
Address 44-12-0 Mariposia Court
Owner
mailing
Address
City lZlp f ,„t" fieeI_. `
City IZip Tel.,
State Lic. City
& Classif. 493919 Lic. # 1231
Designer
Address Tel.
CityI Zip I State
Lic. If
LICENSED CONTRACTOR'S DECLARATION
1 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
SIGNATURE DAT
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 its issuance also
requires the applicant for such permit to rile a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 or 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 civilpenally of not more than rive hundred dollars ($500).
❑ 1, 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 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,
provided that such Improvements are not Intended or offered for sale. If, however, the building
or improvement is sold within one year or completion, the owner -builder will have the burden
of proving that he did not build or inprove for the purpose of sale.)
❑ 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 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 B. & 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
r ❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the permit is for one hundred dollars ($100) valuation
or less.)
I 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
alifornia.DateOwner
NOTICE TO APPLICANT. ff, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
Comply with such Provsions or this 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 if work thereunder is suspended for 180 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
No.
BUILDING: TYPE CONST. OCC: GRP.
05177
A.P. Number
Legal Description
Project Description Phase 1. Plan 4A Lint 4
Sq. Ft. x37 No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
E
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
n A.Q
Const.
Al%f) tin
Mech.
36.01111
Electrical
n
Plumbing
00
S.M.I.
A Inn
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 Z 2 9 $Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
UGH PLUMB.
YARD SPKLR SYSTEM
2ND FL. Sp. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. Sp. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
DRAINAGE PIPING
CAR P. I SQ. FT. ®
GAS (FINAL)
MP. POLE
WALL SQ. FT.
DRINKING FOUNTAIN.
SQ FT ®
WATER HEA R
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
GRADING
cu. yd.
$ plus x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
lQ
f
ROOFING (J
VENTILATION
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, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
HOUSE SEWER
INSULATIONISOUND
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
OUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
UGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR S IC TA
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF. /
[
AS (ROUGH) �%(jO
r
LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
MP. POLE
GROUT
WATER HEA R
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$
LUMBER GR.
FINAL INSP. /,Jj
FRAMING
111
FINAL INSP. //
lQ
f
ROOFING (J
VENTILATION
r� `G
/
e-172
(�r
REMARKS:
000'
FIRE
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHIN f(}
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL