06634 (BLCK)Building
Address 54-085 Mendoza
Owner
HR. & M. DRM
Mailing
Address 54-155 Henodsat
City lZip Tel.
Contractor
Address
Tela
• "
P.O. BOX 1504 No. 06634
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
State Lic.I City
& Classif. Lic. #.
Designer
Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7(IOg) of
effect. Division 3 of the Business and Professions Code, and my license is in full force and
SIGNATURE !�+! +✓�`+•S -as -si"'" DATE
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the 6dractors License Law for the following
reason: (Sec. 7031.5.8ushess 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 pemui to file 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 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 appicant to a c" penalty of rpt more than rive hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sate compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The ComraUors 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 krproverpnt Is sold within one year of conplebon, the owner -budder will have the burden
of proving that he dM not build or irprove for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Bsimess and Professions Code: The Contractor's License Law
does not apply to an owner of property who bolds or irproves thereon, and who contracts for
such projects with a conbactor(s) icersed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. a, g, 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
❑ Copy is filed with the city. O 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 arty manner so as to become subject to the Workers' Compensation
Laws of California
Date owner
NOTICE TO APPLICANT: Il, after making this Certirrcate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such Provsions or ears permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, CW Code.)
Lender's Name
Lender's Address
This is a building permit when property 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
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number 774-222-023
Legal Description
Project Description 3;t retaining wiLU
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
$3.500
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
AMOUNT
.2x
REMARKS `
its` ` SFI` ir01AL' 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
Issued by: Date IIB�$9 Permit
Validated by:
Validati
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT.
FORMS
SEWER OR SEPTIC TANKROUG
- WI NG
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METERTO
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I SQ. FT.
GROUT
WATER HEATER
WALL SO. FT.
FINAL INSP.
DRINKING FOUNTAIN.
SQ FT ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
=$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
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
LAUNDRYTRAY
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
FINISH GRADING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MEC H.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 TANKROUG
- WI NG
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METERTO
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
P/� /� !��/ ►7O /9�
REMARKS:
VENTILATION
FIRE ZONE ROOFING,
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESJINITIALS
GARDEN WALL FINAL
)