RR (10032)Building
Address
Owner
Mailing
Address
Zip
Contractor
Address
Tw�l
"
P.O. BOX 1504 `~ No. 10032
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 9225371 Z rl
BUILDING: TYPE CONST. OCC. GRP.
City Izip I Tel.
State Lic.I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip State I
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.
s tva nnTr..
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, alter, improve, demolish, or repair any structure, prior to its issuance also
ragWres. the applkant for such permit to Fila a signed statement that he Is Ikensed pursuant to
the provisions of the Contractor's Llcanse Law, Chapter 9 (commencing with Section 70001 of
aivislon 3 of the Business and Profa, sEkms Code, or that. he Is exempt therefrom, and itre basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant fo a civil penalty of not more than live hundred dollars (5500).
❑ I, as Owner of the property, or my employees with wages as their sofa compensation, will
do the work, and the structure is nut intended or offered for sale. (Sac. 7044, Buisness and
Professions Code: The Confraclor3 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 improvemanis are not intended or offered for sale. 11, however, the buiwfng
at improvement is sold within one year of completion, the owimr-builder will have the burden
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-
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.)
Polley No Company
L7 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if 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 Cali crnla.
Date Owner _
NOTICE TO APPLICANT: 11, alter making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions 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 certity 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
c8nsttuclloo, and hereby authorize representatives sof Ihls city to enter the above-
mentioned property for Inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
Number
Legal Description
Project Description z,3'_ -'f
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
_S00.:)
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
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 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
A.C. UNIT
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SQ. FT. ®
HEATING (ROUGH)
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
ROUGH WIRING
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
DRAINAGE PIPING
CAR P. SQ. FT. ®
REINF. STEEL
GAS (FINAL)
TEMP. POLE
DRINKING FOUNTAIN
WALL SQ. FT. ®
GROUT
WATER HEATER
SERVICE
URINAL
SQ. FT. @
FINAL INSP.
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
$
FLOOR DRAIN
MECHANICAL FEES
LUMBER GR.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
G�
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.
SQ- FT. ® c
BATH TUB
SPARK ARRESTOR
SQ. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11A c
SEWAGE DISPOSAL
LATHING
SQ.FT.GAR ® 3yic
HOUSE SEWER
MESH
GAS PIPING
PERMIT FEE
INSULATION/SOUND
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.
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./EQUIP.
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
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REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSP EC74R'S SIG NATURE511NITkALS
GARDEN WALL FINAL