BLCK (10981)P.O. BOX 1504 N o . • 10981
Building78-105 CALLE ESTADO 1
Address 53-'3454ENDOZA . LA QUINTA, CALIFORNIA 92253 -
Owner ,
C. HOUSEHOLDER
Mailing BUILDING: TYPE CONST.'- OCC: GRP.
Address 43_7$0+ CULFBDA LN A.P. Number
CityZip Tel.
BERMUDA DUN S 92'2iil ' 345-6116 Legal Description
Contractor Project. Description 83.x. X. c aiC30Di:c1 FEAICB
-Address. SAME* INOTl BEYONP,, \� o nwx FRONT -PROPERTY LYRE'
City :. Zip .
State Lic.
&Classif.. B322893
Arch., Engr.,
-Designer
Address
C
# g: Ft.. No.
ze • - Stories -
ew ❑ Add ❑
Tel. .;
ityZip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (cenc
7000) t.of Division 3 of the Business and Professions Code, and my lico en is
effec
No. Dw. 'z
Units
Repair ❑ Demolition ❑
SIGNATURE SL ( IDATE
OWNER•BUILDERDECLARATION� f"
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 coun-which requires a
permit to construct, alter,. improvty,
e, demolish, or repair any structure, zpar tons issuance also
requires the applicant/or such permit to rile a signed statement that he.is•licensed`pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing %Wh Section 7000) of . r
' 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 Dy: 'any •applicant /or a permit
subjects the applicant to a civil penally o/ not more than rive hundred dollars ($500).
• O 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..r
• Professions Code: The Contractor's License Law does, not•apply to an owner of property, who .COTISt.
buikls or improves thereon and who doessuch work himself or through his own, employees
. - provided that' such improvements are not intended or offered for safe.. B; however, the building
EStlmated.ValuatlOn,:
` AMOUNT
V PERMIT'.'
�- '
' ..
-
_ PIet1. Chk.Dep. -
\Plan Chk. Bal'. 2
-
,.• `-
Mech.... ; �•,-
- _.� + r,
or improvement -Is sold within one year of completion, the owner•bulider will have the burden
• of proving that he did not build or improve for the purpose of sale:J - • ... �
❑ 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.) -
-0 1 am.exempt.under Sec.- B. & P.C. for this reason
Electrical`
, a •- -
Plumbing
..
- S.M-L••'
rA
Grading'.
-
Driveway Enc.
Date Owner
Infrastructure
- WORKERS' COMPENSATION DECLARATION
SIGNATURE SL ( IDATE
OWNER•BUILDERDECLARATION� f"
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 coun-which requires a
permit to construct, alter,. improvty,
e, demolish, or repair any structure, zpar tons issuance also
requires the applicant/or such permit to rile a signed statement that he.is•licensed`pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing %Wh Section 7000) of . r
' 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 Dy: 'any •applicant /or a permit
subjects the applicant to a civil penally o/ not more than rive hundred dollars ($500).
• O 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..r
• Professions Code: The Contractor's License Law does, not•apply to an owner of property, who .COTISt.
buikls or improves thereon and who doessuch work himself or through his own, employees
. - provided that' such improvements are not intended or offered for safe.. B; however, the building
EStlmated.ValuatlOn,:
` AMOUNT
V PERMIT'.'
�- '
' ..
-
_ PIet1. Chk.Dep. -
\Plan Chk. Bal'. 2
-
,.• `-
Mech.... ; �•,-
- _.� + r,
or improvement -Is sold within one year of completion, the owner•bulider will have the burden
• of proving that he did not build or improve for the purpose of sale:J - • ... �
❑ 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.) -
-0 1 am.exempt.under Sec.- B. & P.C. for this reason
Electrical`
, a •- -
Plumbing
..
- S.M-L••'
-.
- �'�. (�'
Grading'.
-
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
❑ Copy.is filed with the city. ' ❑ ,Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
REMARKS
- (This section need not be completed i/ the permit is for one hundred dollars ($100) valuation
- or less.) -
I certifythat in the performance of.thp work for which this permit is issued,'I shall not
=anyperson in any manner so as. to become subject to the Workers' Compensation '
Laws of California.
-
Date Owrier "
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption- you 'should • become •
subject to. the Woikers' Compensation' provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked. -
:, ZONE: ' BY: "
Minimum Setback Distances: - - - -
Front. Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Ihereby 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 Street Setback from.Center Line
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
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.
1 agree to comply with 611 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.
Issued by:
Validated by:
Date Permit -
Signature of applicant Date
Mailing Address
Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
2ND FL. SO. FT.
POR. SQ. FT. ®
GAR. SO. FT. @
CAR P. SQ. FT.
WALL SO. FT. ®
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3Vic
HOUSE SEWER
REMARKS:
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PLCK.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 APPJEQUIP.
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
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION•
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINFTIALS
GARDEN WALL FINAL