04839 (BLCK)0839
P.O. BOX 1504
Building 54-150 CCuanza78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Owner
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 and Professions Code, and my license is in full force and
effect. .1-01 i r . . ,r
SIGNATURE 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
permit to construct, atter, 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 of the Contractor's License Law, Chapter 9 (commencing with Section 7000) or
Division 3 of the Business and Professions Code, or thathe is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penally of not more than five hundred dollars ($500).
❑ I, 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
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 improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ 1, 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 contractors) 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.1,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. : '`t Com an 6'
P Y
❑ 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 any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, alter making this Certificate or 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.
imated
PERMIT
western American
const.
BUILDING: TYPE CONST.
Plan Chk. Bal.
OCC. GRP.
Mailing �
Address
P. 0.
Box 137
Electrical
Side Setback from Property Line
A.P. Number, -.
774-221-007
& 008
City
Zip
Tel. w.
La Quint -a
92253
F
564-7411.
Legal Description
Project Description Retaining
wall �
Contractor
Issued by:
�1Y ®vne�38,�
I agree to comply with all city and county ordinances and state laws relating to building
- 100'-X 3' S
100' X
2'
Address
mentioned property for inspection purposes.
Validated by:
Signature of applicant Date
Mailing Address
P. 0. Box 807
Cit_
yiziI4227r)
Tel.
1.4300
� alms
State Lic.
City
& Classif.
469157
Lic. #
1114
-
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
Arch., Engj:.,
Designer
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
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 and Professions Code, and my license is in full force and
effect. .1-01 i r . . ,r
SIGNATURE 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
permit to construct, atter, 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 of the Contractor's License Law, Chapter 9 (commencing with Section 7000) or
Division 3 of the Business and Professions Code, or thathe is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penally of not more than five hundred dollars ($500).
❑ I, 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
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 improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ 1, 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 contractors) 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.1,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. : '`t Com an 6'
P Y
❑ 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 any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, alter making this Certificate or 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.
imated
PERMIT
AMOUNT
Plan Chk. Dep.
CONSTRUCTION LENDING AGENCY
Plan Chk. Bal.
Side Street Setback from Center Line
Const.
4JU . bo
Mech.
work for which this permit is issued: (Sec. 3097, Civil Code.)
Electrical
Side Setback from Property Line
Plumbing
S.M.I.
«4}
Grading
INSPECTOR
Driveway Enc.
Infrastructure
expiration if work thereunder is suspended for 180 days.
1 certify that I have read this application and state that the above Information is correct.
Issued by:
Date Permit
I agree to comply with all city and county ordinances and state laws relating to building
TOTAL
REMARKS tinr a n•. A^ ,1% -VA b 4
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
City, State, Zip
WHITE - FINANCE, PINK,- APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
,r
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Side Street Setback from Center Line
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.)
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
/
111 1 7! 1788
expiration if work thereunder is suspended for 180 days.
1 certify that I have read this application and state that the above Information is correct.
Issued by:
Date Permit
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.
Validated by:
Signature of applicant Date
Mailing Address
Validation:
City, State, Zip
WHITE - FINANCE, PINK,- APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
,r
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FLSO Fl @r $
UNITS
SLAB GRADE
ROUGH PLUMB
BONDING
YARD SPKLR SYSTEM '
2ND FL SO FT, q
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR SO FT. a
GAS (ROUGH)
METER LOOP
GAR SO. FT.
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO FT.
GROUT
WATER HEATER
WALL SO. FT. @
FINAL INSP.
DRINKING FOUNTAIN
kZ/BPND BEAM ��
WATER SYSTEM
URINAL
SO. FT. 0
_ $
LUMBER GR.
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTONDISHI
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIRE ZONE ROOFING
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FIREPLACE
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. rip c
BATH TUB
MESH
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 11A 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 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.IEOUIP.
97 REINF. STEEL l Q
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
kZ/BPND 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 SIGNATURES11NITIALS
GARDEN WALL FINAL :d