05307 (BLCK)T4ht 4 4 Q"
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 911-1--1341 P,l IM T Rr.-/ LA QUINTA, CALIFORNIA 92253
MR. & MRS. r -HE ! i
Address
City SAME lZip Tel.
State Lic.I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address I Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOWS 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-BUILOER DECLARATION
I hereby affirm that 1 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, demofth, or repair any structure, prior to its issuance also
requires the
nt that he is licensed pursuant to
pvisions applicant for Contractor's License Law, Chapter 9(ccommencing with Sectio7000) of
Division 3 of the Business and Professions Cade, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any vbbtian of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civilpenally of rat more Unan five hundred dollars ($500).
❑ 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, Suisness and
Professions Code: The Contractors License taw does not appy to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided Mat such improvements are not intended or offered for sale. h however, the budding
orimprovement is said within one year of conpleti n, the owner -builder will have the burden
of proving that he did not bun7d 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 Contractors License Law
does not apply to an owner of property who bunds or iriproves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractors License Law.)
❑ 1 am exempt under Sec w_ & 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 fumished.
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 lhg, 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: N, after making Oris;'Certificate of Exemption you should become
subject to the Workers' Compensation proviskxrs of the Labor Code, you must forthwith
comply with such provisions or this penm7 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, CW Code.)
Lender's Name
Lenders Address
This is a building permit when property filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certity 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
Mailing Add
City, State,
No. 05307
BUILDING: TYPE CONST. OCC: GRP.
P. Number 774-791-1119
Legal Description
Project Description iPLD R1 no -V
RETAINING WALL
Sq. Ft. No. No. Dw..
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
7C a1;
Mech.
Electrical
Plumbing
S.M.I.
t
s
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS ts+! a R.e s 4 tt 44 . "t fi:_s'ytt 1 A2.7
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
FINAL DATE
Side Setback from Property Line
INSPECTOR
Issued by: Date l/3UO 9 Permit
Validated
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT. ®
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING.
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SO. FT. ®
FINAL INSP.
BOND BEAM
WATER SYSTEM
DRINKING FOUNTAIN.
WALL SO. FT.
LUMBER GR.
FINAL INSP.
URINAL
SO. FT. @
ROOFING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
VENTILATION
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOXDISH)
APPLIANCE DRYER
FIREPLACE
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/. c
SEWAGE DISPOSAL
SO.FT.GAR ® V4c
HOUSE SEWER
CERT. OCC.
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.
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.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:-
EMARKS:VENTILATION
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
t