07991 (BLCK)Building
Address
Owner
Mailing
Address 41-740 T1in
City I Zip
Contractor
ress
City lZip
ITel. .
t25 I
Tela
State Lic. City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
P.O. BOX 1504 N o.
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
BUILDING: TYPE CONST. DCC: GRP.:
City I ZipI State I
Lic. #
f LICENSED CONTRACTOR'S DECLARATION
I hereb ,affirm that,I am licensed under provisions of Chapter 9 (commencing with Section
7000) of tvision 3•of the Business and Professions Code, and my license is in full force and
effect. h r
SIGNATURE—WSIGNATURE-W i DATE
OWNER -BUILDER DECLARATION
I her by affirm that I am exempt from the Contractor's License Law for the following
reason: ($ec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to,Fonstruct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires fe applicant /or such permit to file a signed statement that he is licensed pursuant to
the prov' ns o/ 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 o/ 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 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 o/ completion, the owner -builder will have the burden
o/ proving that he did not build or improve for the purpose o/ sale.)
❑ 1, as owner of the property,lam exclusively contracting with licensed contractors totcon
�
struct the project. (Sec. 7044,. Business and Professions Code: e-Comracto?s License Law
does not apply to an owner of property�ivho builds or impro�sffhereon, and'who contracts for
such projects with a contracto(s) censed ursuant,to the Co tractor's Licenseyeaw.) x f
❑ 1 am exempt under Sec. B'& P.C,f r this reason
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I haveMa 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. D Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed i/ 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 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
P. Number 774-$51.-022
gal Description Lot 11
oject Description 3; X 90101 w211
07991
F--
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const. 94 nn
Mech.
Electrical
Plumbing
S.M.I.
.14
Grading
Driveway Enc.
Infrastructure
R .f
TOTAL !r; Z.7,/
REMARKS�is�'s "< AA A to ?wwa3�h D
ZONE: BY:
Minimum Setback Distances:
Front Setback frorr Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from'roperty Line
FINAL DATE
INSPECTOR
Issued by: —DateV-2514nPermit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
2ND FL. SO. FT. ®
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. SQ. 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
ROUGH PLUMB.
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
GAS (ROUGH)
LAUNDRYTRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
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
BOND BEAM
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
LUMBER GR.
SO.FT.GAR ® 3/ac
SE SEWER
FRAMING
FINAL INSP.
PIG
tPERMITEFEE
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
ROCKSTORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
i
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
� /
l/
// 000�/� /%
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REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL