11169 (BLCK)wt 4
A SD.3
P.O. BOX 1504 N o . 11169
Building 54565 ROBIO 7&105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Owner
BLANKENSHIP 6DENTREMONT
Mailing
Address SAVE
City Zip Tel.
LA. QUINTA 92253
Contractor
OWNER BUILDER
Address
ty
State Lic. City
& Classif. Lic. #
Arcn.; tngr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am 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 DATE
OWNER -BUILDER DECLARATION'
I hereby affirm that I 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 or not more than rive hundred dollars.($500).
KI, as owner of the property, or my employees with wages as their sole compensation, will
the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Rrofessions 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 contractors) licensed pursuant to the Contractor's License Law.)
O 1, am exempt under. Sec B. & P.C. for this reason
patel�,_a_` _ % Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to 'self -insure, ora certificate of
Worker's Compensation. Insurance,. or a certifiedcopy 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 the work for which this permit is issued, I shall not
gmploy any person in any manner so as to become subject to the Workers' Compensation
Laws of, California.
/Date L --Owner
VVV NOTICE TO APPLICANT: ff, -after making this Certificate ofdExemption 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
BUILDING: TYPE CONST. : OCC: GRP._
A.P. Number
Legal Description
Project Description- 61 o 120' BLOCK WALL
14
Sq. Ft.
Size
No.
Stories
No. Dw.'
Units
New ❑ Add ❑
Alter ❑ Repair ❑ -Demolition ❑
Estimated Valuation
$3,00€3
PERMIT
-
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
$54.00
Mech.
Electrical
f
Plumbing '
S.M.I.
.30
Grading
Driveway Enc.
Infrastructure
TOTAL
''J$54.30
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
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. SO. FT. ®
GAR. SO. FT. ®
CARP. SO. FT. ®
WALL SQ. 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
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FOUND. REINF.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
METER LOOP
LAUNDRY TRAY
AIR HANDLING UNIT CFM
REINF. STEEL
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.
SQ. FT. ® c
BATH TUB
_$
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1% c
SEWAGE DISPOSAL
SQ.FT.GAR ® 1144c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PLCK.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 ZD Z %
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- a�
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESJINITIALS
GARDEN WALL FINAL