05402 (BLCK)T4tyl 4 4 Q"
P.O. BOX 1504
Building z^ - 7&105 CALLE ESTADO
Address J '" d �% i� %j�� (t��- LA OUINTA, CALIFORNIA 92253
Mailing
Address
City lZip Tel.
Contractor
7 ., aL! /-_ V A,", L 13 5,
Address /�
it, o: O'.&'X S 7
City
State Lic. City
& Classif. ,i l, "-7 Lic. #
Arch.; Engr.,
Address I Tel.
City IZip I State I
Lic. #
. LICENSED CONTRACTOR'S DECLARATION
I herebyy affirm that 1 aria licensed under provisions of Chapter 9 (commencing with Section
7011 of.Division 3 of the Business and Professions Code, and my license is in full force and SIGNATURE ' DATE
OWNEWBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,s and Professions Code: Any city or county which requires a
Permit to construct. ager, improve. demolish, or repair any structure, prior to its issuance also
requires the applicant lar such pemr8 to file a signed statement that he is licensed pursuant to
the provlsiws 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
sub)ects the applicant to a civil penalty of not more than rive 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, Guisness and
Professions, Code: The Contmdo Is License Law does not apply to an owner of property who
builds or mrpmves thereon and who does such work himself or through his own employees,
provided that such brrprovements are not intended or offered for sale. It, however, the budding
orimprovement is sold within one year of completion, the owner -builder wifl have the burden
of proving that he did not bulld 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 protects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec a, & 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 dboy thereof. (Sec. 3800, Labor Code.)
Policy No Company; �'�� /
❑ Copy is filed with the city. ❑, Certifi&.copy is hereby furnished.
g.1
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff 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: 8, after making this Certificate of Exemption you should become
suNect 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 pertornance'of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lenders Address
This is a'building permit when property filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 160 days.
I certify that I have read this application and state that, the above information is corecL
1 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
No. 05402-
11LDING: TYPE CONST._ OCC: GRP. -
P. Number -ire .. r`bZ c,
gal Description 1' 1) ' / A
oject Description J e- e,: ! X e d ! 6, /1
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation,,,.
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I...
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
[rr 'r4 @ Hi Fr 9 i2.122 (--64
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
IST FL. SO. 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
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SQ. FT. ®
FINAL INSP.
WALL SQ. FT.
WATER SYSTEM
DRINKING FOUNTAIN.
GRADING
cu. yd.
$ —Plus—X$—=$
URINAL
SQ FT ®
FINAL INSP.
FRAMING
ESTIMATED CONSTRUCTION VALUATION $
WATER 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
FIRE ZONE ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIREPLACE
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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.
SQ. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3Yec
HOUSE SEWER
FINAL INSPECTION -
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
n j
OUND. REINF.,j _0L —,-!r:-
i
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
90—OND BEAM �/d '
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
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION -
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
'
GARDEN WALL FINAL