05710 (BLCK)T,i`4t 4 4 iZ"
0- P.O. BOX 1504
Building 54-145 R> LA pUINTA8-105 C
Address CALIFORNIA 92253
WESTERN AM.ICAR CONSTRUCTION CO.
Mailin
Address P.O. BOX 1379
City Zip Tel. •*
LA QIIZ� u 192253 61.3/564-7411
Contractor
CARY REMUS
P.O. Bflit 807
City 1000 PAWS Zip 92276 Tel., 019/343-26_71
State Lic. City
& Classif. 469157 Lic. # 1114
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
Lic. #
LICENSED CONTRACTORS DECLARATION
1 hereby a"irm'that 1 am licensed under provisions of Chapter 9 (commencing with Section
MCI
Division 3 of the Business and Professions Code, and my license is in full force and
elle �
SIGNATURE- - DATE
.OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reasorr (Sec. 7031.5,11us6ss 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 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 themhom, 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 live hundred dollars (t500).
❑ 1, 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
bukis or rrlproves thereon and who does such work himself or through his own employees,
provided that such improvements are not Intended or offered for sale. N, however, the building
or improvement is sold within one year of completion, the owner-buider will have the burden
of proving that he did not build or improve for the purpose of safe.)
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project (Sec. 7044, Business and Professions Code: The Contactors License Law
does not apply to an owner of property who builds or improves thereon, and who contacts 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 ~
1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy thereof., (Sea. 3800, Labor Code.)
Policy Noe,Company f
❑ Copy is filed with the city. ❑ Certified copy is hereby irnishedw
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed i1 the pemrft is for one hundred dollars ($100) valuation
or fess.)
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
aliforniaDateowner
NOTICE TO APPLICANT. If, after making this Certificate of Exemption you should become
suftject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provsions 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, Ciw7 Code.)
Lenders Name
Lenders Address
This is abuilding permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
1 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
No.
ILDING: TYPE CONST. OCC: GRP.
774-211-019
!. Number
Legal Description
Project Description
f#>g1.RDIM WALL 6' x 30'
05710
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:
Validati
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
f
Estimated Valuation
$750.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
L .O'
Mech.
Electrical
Plumbing
S.M.I.
.07
Grading
Driveway Enc.
Infrastructure
TOTAL
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:
Validati
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. a $
UNITS
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SQ. FT. ®
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT.
DUCT WORK
ROCK STORAGE
/FOUND. REINF. �2
C
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
DRAINAGE PIPING
CAR P. SQ. FT. ®
GROUT
DRINKING FOUNTAIN.
WALL SQ. FT.
FINAL INSP.
L OND BEAM
URINAL
SOFT ®
GRADING
cu. yd.
$ -Plus-X$-=$
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
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
IKITCHEN 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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/a c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
FINISH GRADING
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
/FOUND. REINF. �2
C
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
L OND BEAM
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
t