14309 (BLCK)Building
Address 77-311 POTRERO
Owner
HIM CZEWS=
P.O. BOX 1504 No. 14309.
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Mailing ' OIZAfj -K MGV kW
Address
City=HMAL CITY112234 71212-8085'
Contractor
SAME
Address.
State Lic. City
& Classif.. 502905 8 Lic. # OU file
Arch., Engr.,
Designer
Address Tel.
CityZip 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 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 anystructure, 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 thathe 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 ($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 Improvefor 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 fora
such projects with a contractors) pcensed 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.)
Policy No.' • Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed 9 the permit is for one hundred dollars ($100) valuation
or less.)
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
Legal Description
Project Description
1304 — 4" WALL
109 5' WALL
15' — 6' 'BALL
Sq. Ft. No. No. Dw.
Size ` Stories Units
New ❑ Add O Alter 0 Repair ❑ Demolition O
Estimated Valuation
i
PERMIT AMOUNT.
Plan Chk. Dep.
Plan Chk. Bal.*
Const. $72.00
Mech.
Electrical
Plumbing
. S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL S•
REMARKS t
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
' bate Owner
• NOTICE TO.APPUCANT: d, after making this Certificate of Exemption you should become
ZONE:
BY:
subject to the Workers' C0mpens8tf0n provisions' of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked. -
Minimum -Setback Distances: -
Front Setback from Center Line
Rear Setback from Rear Prop. Line
WARNING: FAILURE TO SECURE WORKERS'COMPENSATIONCOVERAGE IS UNLAWFUL,' AND '
Side Street Setback from Center Line
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UPTO ONE
HUNDRED.THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION,
Side Setback from Property, Line
DAMAGES AS PROVIDED FOR INSECTION 3706 OF THE LABOR' CODE, INTEREST, AND
ATTORNEY'S FEES. -
FINAL DATE
INSPECTOR
permit whenfilled out, signed and'validated, and is subject to
This Is a buildingproperly 9 i
r'
expiration if work thereunder is suspended for 180 days.
j
11 FM�
I certify that I have read this application and state that the above information is correct.
Issued by:
Date t
I agree to comply with all city and county ordinances and state.laws relating to building.
I
construction, and hereby authorize representatives of this city to enter the above-.
I
I
mentioned property for inspection purposes.. -
Validated by:
Signature of applicant Date
NOV 0 9 19 11
Mailing Address
Validation:
City, State, Zip
_-
- ; ?V---------------------------
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBIW%3 FEF S
IST FL. SO. FT. ® $
2ND FL. SO. FT.
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. SQ. FT.
WALL SQ. FT.
' SO. FT. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property lax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APP./EQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
REMARKS:
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
/
ffeFOUND. REINF. / L
ll[
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM I L Y/V /
d l
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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIAIS
GARDEN WALL FINAL