9511 (BLCK)4
P.O. BOX 1504 N o . " 9 511
Building 52-845 Bermudas LA QUINTA, CALIFORNIA92253
Address �� `
Owner
SuTaio iguchi C5
Mailing BUILDING: TYPE CONST. OCC: GRP. -
Address game
A.P. Number
City Zip Tel.
Aja Qt13 i2+_a 92253 6Legal Description
Contractor194 ` of 5' wood fence
Owner/Builder Project Description
State Lic. I City
& Classif. Lic. #
Arch., Engr:,
Designer l
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 Contractors License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, after, 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 than five hundred dollars.(8500).
Was 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. g, 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.)
_O 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.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date Owner 7 /
WORKERS' COMPENSATION DECLARATION
I hereby affirm -that I have a certificate of consent to self-insure,'or a certificate of
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. .Company
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed i1 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 anyperson in any manner so as to become subject to the Worrkers' Compensation
Laws of California.
Date Owner -^-
NOTICE TO - APPLICANT: If 'after making this Cert ffcate ,of.7Exemption' you should become
subject td the Workers' om.,_ sation 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.)
Lenders Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it 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
Sq. Ft.
Size 194
No. No. Dw.
Stories Units
New ❑ Add ❑
" Alter ❑ Repair ❑ Demolition ❑
Est imated-Val uation
7649.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
$5 • Uti
Mech.
Electrical
Plumbing
S.M.I.
• LU
Grading
Driveway Enc.
Infrastructure
TOTAL
4_5 • L
REMARKS
Jo WO j
a4 Lr .r <<va• r . v .. - -
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
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. @
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. I SQ. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SQ. Fi.
OTHER APPJEOUIP.
DRINKING FOUNTAIN.
SO FT ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
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
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 I
IBATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SO.FT.GAR ® V4c
HOUSE SEWER
LATHING
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.
$ Ptus x$
_$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
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