04075 (BLCK)Building
Address
Owner
4 4 Qum& 0 4 0 7 1`5
P.O. BOX 1504~r
46-800 MCni&;D FSS LA QUINTACCALIFORNIA 92253
:ftp. PINGER
Mailing
Address
City Zip Tel.
L. gunin 92253
Contractor
SHELL EEOR G.10181 INC,
Address 41-595 Lrm MLL ROO I
City Zip Tel.
13MMMA DUNES 1}2201 345-6447
StateiCity
&
• Classit.f. 480466 Z Lic. #
Arch., Engr.,
Designer
Address I Tel.
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provisions of Chapter 9 (commencing with Section
7000,0I
Division 3 of the Business and Professions Code; and my license is in full force and '
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to rile 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 applicant to a civil penalty of not more than five hundred dollars ($500).
❑ 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
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
Of 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.)
❑ 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.)
O 1 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 copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ 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 (E100) 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, after making this Certificate of 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.
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 FINAL DATE INSPECTOR
This is a building permit when properly filled out, signed and validated, and is subject to �//�`�
expiration if work thereunder is suspended for 180 days. PV
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:
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number 617-063-001
Legal Description
Project Description 3' X 41' BLOCK VALL
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
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
�r - ..rte..:.. ,..i. - n _...,. ..�: y.. _ ._____ ... .. .-.. .++_... .,�. __ . ,. -.. ....�� .. ...... .-. .s... to .. ... . .... ...
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demdition ❑
Estimated Valuation
1,025
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
20,00
Mech.
Electrical
Plumbing
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
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
�r - ..rte..:.. ,..i. - n _...,. ..�: y.. _ ._____ ... .. .-.. .++_... .,�. __ . ,. -.. ....�� .. ...... .-. .s... to .. ... . .... ...
CONSTRUCTION ESTIMATL
NO. ELECTRICAL FEES
NO. PLUMBING FEES
iSl FL SO FT rp $
UNITS
SLAB GRADE
ROUGH PLUMB
BONDING
YARD SPKLR SYSTEM
2ND FL SO FT. a
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR SO FT. 7t
GAS (ROUGH)
METER LOOP
GAR SO. FT. C1
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CARP. SO FT. 0
GROUT//
WATER HEATER
WALL SO. FT. (d
FINAL INSP.
DRINKING FOUNTAIN
OND BEAM/n Z
�v O
WATER SYSTEM
URINAL
SO. FT. fd
-$
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.000L HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
VENTILATION
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. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID g 1 V. c
SEWAGE DISPOSAL
SO.FT.GAR sr Y c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE bL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB FEE
STRUCTURE PLUMBING ELECTRICAL . HEATING 8 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
ROCKSTORAGE
/FOUND. REINF —,/r_ FT/
JJ O O
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT//
WATER HEATER
SERVICE
FINAL INSP.
OND BEAM/n Z
�v O
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
INSULATIONISOUND
FINISH GRADING
l /
FINAL INSPECTION& -JL/' (Y
P
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESlINITIALS
GARDEN WALL FINAL