09173 (BLCK)414.
P.O. BOX 1504 No. 09173
Building 78-105 CALLE ESTADO
Address 52-5$0 Rubio LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address P.O. Box 1585'
City Zip Tel.
La ouinta 1 92253 1
Contractor
ress
Zip I Tel.:
State Lica City
&.'Classif. Lic. #
Arch.,. Engr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that I em licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect. `
SIGNATURE t DATE
OW NER-BUILDER' DECLARATION
I hereby affirm'that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,6usiness• and Professions Code: Any city or county which requires 'a
permit to construct, after, Improve, demolish, or repair any structure, prior to its issuance also
.requires the applicant for such permit to file a signed. statement that he is licensed pursuant to
the.provisions of the Contractor's License Law, Chapter 9$(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).
•❑ I;.as owner of the property, or my employees with wages as.their sole compensation, will
' do the work, and the structure isnot 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
.build§or improves thereon and- who ..does such work himself:. or through his own employees,
provided that'such improvements are not intended or offered llor 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 buildsor improvesthereon, 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.
E
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 permitis issued, I shall not
employ any person imany 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 stale 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
WING: TYPE CONST. OCC: GRP.
P. Number
Legal Description
Project Description.
1002 of 5' Block Wall
TOTAL 45.14
REMARKS
ZONE: BY,:
Minimum Setback Distances. r t
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
Issued by:
Validated by:_
Validati
INSPECTOR
Permit
Sq. Ft. No.
Size Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑
Repair ❑ Demolition ❑
Estimated ValuatI83.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
45.00
Mech.
Electrical
Plumbing
S.M.I.
a14
Grading
Driveway Enc.
Infrastructure
TOTAL 45.14
REMARKS
ZONE: BY,:
Minimum Setback Distances. r t
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
Issued by:
Validated by:_
Validati
INSPECTOR
Permit
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC.
BAR SINK ~�
POR. SQ. FT.
ROCK STORAGE
GAS (ROUGH)
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO. FT. ®
WATER HEATER
SERVICE
WALL SQ. FT.
DRINKING FOUNTAIN.
SO FT ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WAIER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 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
SETBACK
SLAB GRADE
FORMS
FOUND. REINF.
REINF. STEEL
GROUT
BOND BEAM
LUMBER GR.
FRAMING
ROOFING
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
GARDEN WALL FINAL
PLUMBING ELECTRICAL HEATING & AIR GOND. SOLAR
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
GAS (FINAL)
TEMP. POLE
WATER HEATER
SERVICE
FINAL INSP.
WATER SYSTEM
GRADING
FINAL INSP cu. yd.
FINAL INSP. $ plus x$
�/
f° A�
' REMARKS: