09093 (PLBG)Building
Address
' u
P.O. BOX 1504
78-105 CALLE ESTADO
!RAN7A LA QUINTA, CALIFORNIA 92253
'Mailing
Address SAME
City1Z92253
ip Tel.
LA OUIRTA.CA
Contractor
Aaaress
P. Q. BOK 1908
City lZip Tela
State Lic. I City
& Classif. 256184 Lic. # 194
Arch., Engr.,
Designer
Address Tel.
City ( Zip ( State
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 end Professions God and my license is in/{ull fore and
effect.f t1 f(i fr ,
SIGNATURE rte- I DATE
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
I permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions or 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 or Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty or not more than five 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
Professions Code: ;The Contractor's License Law does not apply to an owner of property who
I builds or improves thereon and who does such work himself or through his own employees,
F 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
or proving that he did not build or improve for the purpose of sale.)
01, 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 or property who builds or improves thereon, and who contracts tot
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ I 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 cop thereof. Sec. 3800, Labor Code.)
Polic�y,t�l^g'�035-1_-90 company S'i'l�,'i'R �liIND
O 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 ($100) valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the'Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate or Exemption you should become
subject to the- Workers' Compensation provisions or the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.. .
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
No. 090§3
SEWER
BUILDING- TYPE CONST. HOOKUP OCC. GRP.
A.P. Number 774-211-003
Legal Description
Project Description spyr.R HOOKUP
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
A30,00
S. M. 1.
Grading
Driveway Enc.
Infrastructure -
��''�
, xtx►iira:��rariu. �fYi4!»w'iL �- y,tt �vtr
TOTAL
dito. 00
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line,
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
T
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ®$
UNITS
COLL. AREA
2ND FL. SQ. FT.
ROUGH PLUMB.
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
SEWER OR SEPTIC TANK
ROUGH WIRING
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
FOUND. REINF.
GAS (ROUGH)
DRAINAGE PIPING
CAR P. SD. FT.
HEATING (FINAL)
OTHER APPJEQUIP.
WALL SQ. FT.
GAS (FINAL)
DRINKING FOUNTAIN.
SQ FT ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER HEATER
WAl ER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FINAL INSP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
7
�
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.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
LATHING
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 GOND. 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
7
�
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL