03903 (ELEC)03900
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 54-024 Avenida .Bel"YrttldaS LA QUINTA, CALIFORNIA_ 92.253
Owner
Mailing y BUILDING: TYPE CONST. OCC. GRP.
Address Some P. 0. B= 957. A.P. Number 774-225-016
City lZip JTel.
1 - .
Contractor owner/Bu.ildor
City lZip I Tel.
State Lic. City
& Classif. Lic. #
Arch., Engr.,-•
Designer
Address
CityI Zip I State I
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, 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 rive hundred dollars ($500).
El 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 or 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.)
!t
O 1 am exempt under Sec. f B. & P.C. for this reason
WORKERS' COMPENSATION DECLARATION V
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
O Copy is filed with the city. O 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 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
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.
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
_egal Description
project Description misc. electrical
+4•:x WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ ' Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$200.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
4;4v s USI
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
4%Q'. i W,A.0 V9V4TAI4---I' 9—R4't
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 IINSPEk�C)OVFi
Issued by: Date Permit
Validated by:
Validation:
+4•:x WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
ISI FL SO Fl i(a S
UNITS
A.C. UNIT
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL SO FT.@
BONDING
HEATING (ROUGH)
MOBILEHOME SVC.
BAR SINK
POR SO FT. a
SEWER OR SEPTIC TANK
GAR SO. FT. @
POWER OUTLET
ROOF DRAINS
FOUND. REINF.
DRAINAGE PIPING
CARP. SO FT. @
METER LOOP
HEATING (FINAL)
'SJO FT. @
WALL - S
REINF. STEEL
DRINKING FOUNTAIN
GAS (FINAL)
URINAL
SO. FT. (a
GROUT
ESTIMATED CONSTRUCTION VALUATION $
WATER HEATER
WATER PIPING
_NOTE' Not to be used as property tax valuation _
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASH ER(AUTONDISH)
APPLIANCE - DRYER
LUMBER GR.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
-FRAMING
LAUNDRYTRAY
AIR HANDLING UNIT CFM
ROOFING +
t
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
FIREPLACE
SO. FT. g c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 1+i: c
SEWAGE DISPOSAL
SO.FT.GAR @ 3�.c
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 8 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 xS
=S
LUMBER GR.
FINAL INSP.
-FRAMING
FINAL INSP.
ROOFING +
t
{
a
- - - -
I
}
f
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
I
,�- '�',r�., .,'•sir. ..IJj%i+. ..'f�f�a �' .;t:.. ;ltJ �. i.:. ,11:-+: ' 1