12063 (PLBG)Building
Address
444
P.O. BOX 1504 No. 12063
78-105 CALLE ESTADO ,
78--.580 '.Wy 12i LA QUINTA, CALIFORNIA 92253
-Gearil Hill BUILDING' TYPE CONST • OCC' GRP
Mailing
Address A.P. Number
City Zip Tel.
Legal Description
„Contractor I Interior or boiler room•' . Project Description
lsiX'12C'343 i $chAmberg
-Address
215• CalleeMayor
cit�yedondo Beach z1pI9fl277
;State Lic.
Classif., S 498199
Tel.'
(310378-3846
City
Lic. # 28.&a
Designer.
.r Address Tel.
;City Zip State11`�r�
Lic. # `
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am Itcensed,underprovisions 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 f.>r�•r»x-cd� l r r•?r'�
t SIGNATURE- A DATE
r OWNER -BUILDER DECLARATION
heretiq,affirm'the I am exempt from the Contractor's License Law for the following
reason[ (Sec. 7031: 5;Business and Pro/essions Code: Any city or`county which requires a
,perriilt construcl alter, improve, demolish, or repair any structure; }}, poor to its issuance also
requires,_the';applicant for such permit -to lite a signed statement that he is licensed pursuant to
_the -provisions o/t
h
e Contractor's License Law, Chapter 9. (commencing with Section 7000) of
..Division `3 :0 the Elusiness and Pro/essions Code, or that ha is exempt therefrom, and the basis
-`-tor the>a/'.,.,''exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects he applicant toa civil penalty o/ not more than live hundred dollars.(S500).
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 o/ 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.)
O 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 ownero/ 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. '�;/ J ( Company r" 3"Ak 'a:• /r lJArdt
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 ($700) valuation
or less.)
1 certify that in the performance of th8 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
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
REMARKS
ZONE: BY:
Minimum Setback Distances:
y
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:
'Sq. Ft.
Size
No. NO. Dw.
Stories . Units '
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$4,000.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
90.W
Const.
44.45
Mech.
Electrical
Plumbing
1.57
S.M.I.
Grading
Driveway Enc.
Infrastructure
Lx n
TOTAL
136.02
REMARKS
ZONE: BY:
Minimum Setback Distances:
y
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. SQ. FT. @ $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SQ. FT. @
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO. FT. @
GROUT
WATER HEATER
WALL SQ. FT. @
FINAL INSP.
DRINKING FOUNTAIN.
SO. FT. @
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
VENTILATION
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING
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
LATHING
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID @ 1+/4 c
SEWAGE DISPOSAL
,
SQ.FT.GAR @ 3/ac
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 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
�J
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
,
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL