15863 (BLCK)44
P.O. BOX 1504
Brading 52-925 Ave. Bermudas 78-495 CALLE TAMPICO
Address LA OUINTA, CALIFORNIA 92253
Owner Mike Seems
Mailing
Address Sate
City Zip ITel-
'r-La
Quinta R CA 92253 30411I
Contractor.
Ellington. Masonry
68675 Panorama
City Zj Tela
Cathedratl Citi C$R 92234 3Zfl--3483.
State Lic. City
& Classif.. 497804 Lic. # 3607
Designer -
Address Tel.
City Zip State
V, -Lic. #
LICENSED CONTRACTOR'S DECLARATION
it hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
000) of Divisioff-t emu iness and Professions Code, and my license is in full force and
r 3/
• SIGNATU y-. ./ �` DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Bustness 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 file 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 exemptlan. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civilpenafty of not more than five 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, 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 inprove 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) [icensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & 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.)
Poli y 'No 'K Company
dopy is filed with the city; ❑ Certified copy is hereby furnished.
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 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. If, .after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions or the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES, UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 160 days. . -
I certify that 1 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. 15863
11LDING: TYPE CONST. OCC: GRP.
P. Number
Project Description 80
black wall
1.f. of 4' high garden
Minimum Setback
Distances:
Front Set
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Side -Se -4
FINAL DATE
Issued by:
Validated by:
Estimated Valuation
$1,280.00
t
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
45.00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
45.00
REMARKS.
ZONE:
BY:_
Minimum Setback
Distances:
Front Set
Rear Setl
Side Sye
Side -Se -4
FINAL DATE
Issued by:
Validated by:
Validation:
,Cea1er Line
Rear p. Line
( 1[;E Z(z ter Line
NS�E�T0R
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBIW FEES
1ST FL. SQ. FT. ® $
UNITS
t
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
SEWER OR SEPTIC TANK
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. I SQ. FT.
OTHER APPJEQUIP.
DRAINAGE PIPING
WALL SQ. FT.
TEMP. POLE
DRINKING FOUNTAIN
SQ. FT. a
GROUT
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
=$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
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,TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ® c
BATH TUB
SPARK ARRESTOR
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 114 c
SEWAGE DISPOSAL
LATHING
SO.FT.GAR ® 3/4c
HOUSE SEWER
MESH
GAS PIPING
PERMIT FEE
INSULATIONISOUND
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 APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM /Q
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
U.3d OV Vjjqp,�, 0, Oj.Lo3rtj,., I
S III
BOW
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41 jA.