002638 (BLCK)� ��tMuaA
Building178020 �
Address 1
cc 4
Mailing
Address P.O. BMC 146$ '
City Izip ITel.
% cairg I -
tractor
Address
40 - La -M
City JZip Tela
State Lic. City
& Classif. Lic. #
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
MGM, tngr.,
Designer
Address Tel.
City Zip State
Lic: #
LICENSED CONTRACTOR'S DECLARATION
I 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 of not more thanrivehundred 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 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 contractor(s) licensed pursuant to the Contractor's License Law.)
❑ I am exempt under Sec. B. & P.C. for this reason
Date Owner.
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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. furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE .
(This section need not be completed f1 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
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 '
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.
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 1 —Date—
Mailing
ateMailing Address
City, State, Zip
r
HARD COPY
No. 002638
BUILDING: TYPE CONST: OCC: GRP,
A.P. Number
Legal Description
Project Description
ZONE:
BY:
Minimum Setback Distances:
No. No. Dw.
Sq. Ft. A()Q 1n ft
Size •Stories Units
New D Add ❑ Alter ❑ Repair ❑
Demolition ❑
Side Street Setback from Center Line
400 11;f. £t. of, 6-foWhigh tom•
6` >i Ui* fey= f5d security pins.
INSPECTOR
Issued by:
Date 10"`W F'Permit
Validated by:
Estimated Valuation 1r500.00
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
17.22
Const.
«..6.5.4
Mech.
Electrical
Plumbing
S.M.L.
..50
Grading
Driveway Enc.
Infrastructure
TOTAL
44.22
REMARKS
ZONE:
BY:
Minimum Setback Distances:
Front Setback.from Center Line
Rear Setback from Reay Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date 10"`W F'Permit
Validated by:
Validation:
A6502
10 10 44,22 U
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
COLL. AREA
`
ROUGH PLUMB.
YARD SPKLR SYSTEM
2ND FL. SQ. FT. ®
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
METER LOOP
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SQ. FT. 0
GAS (FINAL)
WALL SQ. FT. ®
DRINKING FOUNTAIN
SQ. FT. ®
WATER HEATER
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
GRADING
cu. yd.
$ plus x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
REMARKS:
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
SH
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 B.AIR GOND. 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
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
R. FIREWALL
T ING
SH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS,
GARDEN WALL FINAL