05399 (PLBG)P.O. BOX 1504 No. 05399
Building dy. 78-105 CALLE ESTADO
Address G� J°�`"Pr'1 tJ'- LA QUINTA, CALIFORNIA 92253
Owner gyp j
Mailing
BUILDING: TYPE CONST. OCC: GRP.
Address f= �.;;.:•. A.P. Number ✓ I 1
City Zip
, Legal Description
Contractor Project Description
Address` I
City D Zip Tel.:
State Lic. I City
& Classif-mc_ r } Lic. #
Arch., Engr.,
Designer
Address Tel.
City ( Zip ( State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that ['am licensed under provisions of Chapter 9 (commencing with Section
7000) of bivision 3 q(•i�lia,Business and Professions Code ?and my Incense is in full force and
effect. cox ,>• r b. tis �'j. -��!`../ 1
SIGNATURE IF DATE
OWNER -BUILDER DECLARATION
I hereby affirin that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Busmess and Professions Code: Any city or county which requires a
permit to construct, alter, bnpmve, 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 appfcant to a civilpenalty of not more than five hundred dollars ($500).
❑ 1, 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
bud& 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 said 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.)
❑ 1 am exwnpt under Sec B. 8 P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of,consih%to self -insure, or a certificate of
Worker's Compensation Insurance, or a ceRifi ,copy,ihereef. (Sec. 3800, Labor Code.)
Policy No Company k �h f
O Copy is filed with the city. ❑ Certified cop is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(rhis section need not be completed if the permit is for one hundred dollars (5700) valuation
of 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: ff, 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
Ihereby 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
Lenders 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
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ 'Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing ,
S.M.I.
r t'
Grading
Driveway Enc.
`
Infrastructure
TOTAL
'~ . -7
REMARKS
ZONE: BY:
Minimum Setback Distances:
Fiont.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:
NO. ELECTRICAL FEES
NO. PLUMBING FEES
UNITS
A.C. UNIT
COLL. AREA
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
IROOF DRAINS
FORMS
DRAINAGE PIPING
ROUGH WIRING.
DRINKING FOUNTAIN.
ROCK STORAGE
URINAL
GAS OUGH)
WATER PIPING
HEATING (FINAL)
FLOOR DRAIN
REINF. STEEL
WATER SOFTENER
SIGN
WASHER(AUTO)(DISH)
GARBAGE DISPOSAL
WATER HEATER
LAUNDRY TRAY
FINAL INSP.
KITCHEN SINK
TEMP USE PERMIT SVC
WATER CLOSET'
POLE, TEMIPERM
LAVATORY
AMPERES SERV ENT
SHOWER
SO. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
SO. FT. RESID ® 1 V c
SEWAGE DISPOSAL
SO.FT.GAR ® 314c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PLCK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
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 OUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
S i�
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
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL