10067 (BLCK):`
P.O. BOX 1504
Building78--271 High -way Q
111 LA UINTA8-105 C
AddressCALIFORNIA 92253
Owner
Von E s 10175
Mailing
Address ISceme
City Zip Tel.
La Qainta 92253 564-2001
Hussmann Corp.
Address
13770 Ramona Ave
CityZips Tel.:
Chino 51.714 714/590-4910
State Lic. City
& Classif. 304926 Lic. # 1762
Arch., Engr.,
Designer Gregory Hammers
Address Tel.
414913 M. Floridia 714/652-5876
City Zip State
Hemet 92344 Lic. #
LICENSED CONTRACTOR'S DECLARATION
Fhereby affirm'that I am licensed under provisions.of Chapter 9 (commencing with Section
7000)rof Division 3 of the Business and Professions Code, and my license is in full force and
Aeffect:.;;
,�1GNATURE DATE
—' OWNER -BUILDER DECLARATION
I hereby affirm that l 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, 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 rive hundred dollars.($500). '
O 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.)
0 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.)
❑ 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..($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 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 constructiondending 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 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
No. 10067
BUILDING: TYPE CONST.. OCC: GRP.
A.P. Number
,Legal Description
Project Description
50' of 3'2' block wall to
enclose shopping carts
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
900.40
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
25.00
Mech.
Electrical
Plumbing
'
S.M.I.
.10
Grading
Driveway Enc.
Infrastructure
TOTAL
25.10
REMARKS
'
„t,. T. ..vH0.:Y! Y;
1w.•l YA4e A, ... k. ...a
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. SO. FT. ® $
2ND FL SQ. FT.
POR SO FT ®
GAR. SO. FT. ®
CARP. SO. FT.
WALL SO. FT. ®
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS l
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOXDISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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
SO. FT. ®c
IWATER HEATER
MAX HEATER OUTPUT, B.T.U. '
SO. FT. RESID @ 1 Vi c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
HOUSE SEWER
REMARKS:
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 l
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 �3 R/L
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 SIGNATURES/INITIALS
GARDEN WALL FINAL