14624 (BLCK)54-024 P.O. BOX 1504
Buildingg,, 78-495 CALLE TAMPICO
Ad�Fes- 24 Ave • Bermudas LA QUINTA, CALIFORNIA 92253
Owner
Poppy Owen
Mailing
Address P.O. BOX 252
City FZ
Tel.
La Quinta, CA2253
Contractor
Omftek/Du .l dek
Address..
City Zip Tela
State Lic: City
& Classif.. Lic. #
Arch., Engr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION W
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
70DO) 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 (5500).
I, as owner.of the property, or my employees with wages as their sole compensation, will
o 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 knproves 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) [icensed pursuant to the Contractor's License Law.)
j ❑ 1 am exempt under Sec - B. & P.C. for thireason
iDate LL -2_-_/b - 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, ora certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city.. O Certified copy is hereby furnished.
i•
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is, for one hundred dollars (S100) valuation -
or less.)
j I certify that in the performance of thg work for which this permit is issued, I shall not
employ any pparson in any manner so as G b6ccome subject to the Workers' Compensation
Laws of Call bm'a!` f -
Data itis Owner _ #)
, LNOTICE TO APPLICANT: ft, after making` this -Cert ibate of Exemption you should become
I-Tsubject to the Workers' Compensatbn provisions of 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
ATTORNEYS FEES. FINAL DATE INSPECTOR
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. Issued by: Date Permit
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. Validated by:
BUILDING: TYPE CONST
Number
No. 14624
OCC. GRP.:
Legal Description
Project Description &5 • of 41 high black wall
- (garden)
Sq. Ft. No. No. Dw.
Size - Stories Units
New ❑ Add O Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation $1,191.00
1
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
45.04
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
+
Al
TOTAL =
45.00
REMARKS
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
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
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
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I SO. FT. ®
GROUT
WATER HEATER
WALL SO. Ff. ®
FINAL INSP.
DRINKING FOUNTAIN
SO. FT. ®
I
URINAL
ESTIMATED CONSTRUCTION VALUATION $
=$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
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
VENTILATION
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING
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
LATHING
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.Ff.GAR ® V4c
HOUSE SEWER
FINISH GRADING
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 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
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
GARDEN WALL FINAL
INSPECTOR'S SIGNATURES11NITIALS