9886 (RPL)91
Building 51-345 Rubio
Address
,dim Belknap
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Mailing
Address Box 1062
City Zip Tel.
l,a Quint:a 1 92253
Contracr
Wn tor/Builder
Address
ity Izip
State Lic.I City
& Classif. Lic. #
Arcn., tngr.,
Designer
Address Tel.
City IZip I State
Lic: #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
t.
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effec
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, after, 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 Ucense 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 of not more than five hundred dollars (8500).
Wh 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
Pro/essions 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.)
❑ 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.)
v
0 1 am exempt under Sec. B. & P.C. for this reason
Date Owner J/
t
WORKERS' COMPENSATION DECLARATION
1 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.)
Polic No.Company
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 tho 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.)
Lenders 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
• • 9
7, ( on i •-
BUILDING: TYPE CONST. OCC: GRP.-
A.P. Number
Legal Description
Project Description
POOL ONLY
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
-6,000
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
52.65
Const.
81.00
Mech.
24.00
Electrical'
30.00
Plumbing
21.00
S.M.I.
.60
Grading
Driveway Enc.
Infrastructure
TOTAL
Z o. z 5
REMARKS
A�-i A.^9 7' d'a AA�''3 +t H
'1
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. SQ. FT. $
2ND FL SQ. FT.
POR. SQ. FT. ®
GAR. SO. Fr. ®
CAR P. SQ. Ff.
WALL SQ. FT. ®
SO FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SY46TEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
SLAB GRADE
FLOOR DRAIN
MECHANICAL FEES
BONDING
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DI SH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
DUCT WORK
LAUNDRY TRAY
AIR HANDLING UNIT CFM
GAS (ROUGH)
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
WATER HEATER
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
BOND BEAM
SQ.FT.GAR ® V4c
HOUSE SEWER
FINAL INSP.
$
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 L
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
FINAL INSP.
$
GRADING
cu. yd.
plus x$
=$
LUMBER GR.
FRAMING
FINAL INSP.
ROOFINGPlt5
dw4f
� /�/
REMARKS:
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITLALS
GARDEN WALL FINAL