05854 (RPL)Building C2-72o
Address / J
Owner
ilk, V If-5 7, C--9 N
Mailing
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Address __ 4 2-5 /S eP,/, CJp ,A 5
City Zip Tel.
1-14 Q LA,/V /A i'zZ33 51.oq-7Y.1/
Contractor
Address
t 3 `10 if S rx i 14 �T
o /V 1'72.z 2-
State Lic. City
& Classif. S U Lic. #
Arch., Engr.,
Designer
Address I Tel.
City r Zip I State
I Lic. #
LICENSED CONTRACTOR'S DECLARATION
I heretry affirm that i am licensed under provisions of Chap [or 9 {commencing with Section
7[t0(7j of (vision 3 of the Business and Professions Code, and my license is in full force and
effeCL
SIGNATURE OAiE
OMINER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License taw for the following
reasam fSoc. 703CS.Buswiess and Professions rode: Any city or county which fegdras a
parmid to consrract, after, improve, demaish. or repair any Structure. prior to Its issuance also
requires the appiCarrt for such perms fo fire a signed statement that he is licensed pursuant to
Ilia pmvi5iem,. of the Contractors License Law, Chaplet 9 (cammencin0 with Section 7000) of
DWSPorr 3 of tfxr BUSlness and PralesSkM code, or thathe is exarrot Ihefefrom, and the basis
far the alleged exempt ban- Any viwkghm of Seclion 7031.5 by any appecanf for a pemrd
subje&S the appric81rd 10 a cfviparraRy of nor mom than 11vo hundred dollars (S500),
❑ 1, as owner of the property, or my employees with wages as Ihelr sale compensation, will
do the wort4 and the structure is not intended or offered for sale. (Sec. 7044, arisness and
Professions Cade. The Corrfracfars [scene Law does not apply fo on awnsr of property who
bubds or irpmves 0+ereon and who does such work himself or Through his own empfoyoes,
praw'ded thud such irirvrmnarRs are no: inlemded or offerers for saleit, however, the burkfhv
ar ir4nrovamenf is sold within one year of compfolknn, the owner-buNder wi# have the burden
of proving Unit he did not hrii or irprove for the purpose of sale.)
❑ 1, as owner of lire property, am exclusively contracting with licensed contractors to con-
struct the project f,%m 7044. &Fsmess and Professons Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such pn*90s wRh a conbaclor(s) icensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec- R. & P.C. for this reason _
Date Owner
WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers Compensasion Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No.- _ Company ad!'
❑ Copy is filed with the city- El Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be compflNed d The permit is for one hundred dollars ($100) raruation
all loss.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any person In any manner sit as to become subject to the Workers' Compensation
Laws of California --
Date - Owner
NOTICE TO APPLICANT 8 after mating This Certificate of Exemplion you should become
subject to Ifie ttrbrkers' Ccrrpensaf= pmvWons of the Labor Code, you must forthwith
comply wih such prov®brs or dv-s pemir ~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. fSec. 3097, Civil Code.)
Lenders Name _
Lenders Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work lbefounder is suspended for 180 days.
I certify [hat I have read this eppl€cat€on and state that the above information Is correct
I agree to comply wilh all City and county ordinances and state laws relating to building
construction. and hereby aulhoraa representatives -of this city to enter the above -
mentioned property low inspection purposes_
Signature of applicant_ Date
Mailing Address
City, State, Zip
No. 05854
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number -7-7 41— %2 /'—•,d 01
Legal Description /V Bak 2-2.
Project Description 0 fi P
if
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑
Demolition ❑
Estimated Valuation
F
f/
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
7 j"
Const.
, p p
Mech.
Z
, p
Electrical
Plumbing
a
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.
2ND FL.
POR.
GAR.
CAR P.
WALL
ESTIMATED CONSTRUCTION
SO. FT. ®
SQ. FT.
SO. FT.
SQ. FT. ®
SQ. FT.
SO. FT.
SQ. FT. @
VALUATION
$
UNITS
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
$
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, TEMIPERM
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.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR @ 3/4c
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 FI FCTRICAL 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
R
Per- G�ti i
G�
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURE511NiTIALS
GARDEN WALL FINAL