9626 (SFD)4
P.O. BOX 1504
Building 78-620 Carnes Circle 78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Mailing
Address 1021 Bastanchury Road
City I zip ITel. I
Acacia Cwnsl
Address .. .
City same 71
State Lic. City
&Class'f- B 21*23954 LiC.# 1612
Arch., Engr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed und6r 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. f
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractorjs 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 five hundred dollar's ($500).
0 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 S�ale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or bnp-ves 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 ivill have the,burden
of proving that he did not build or improve for the purpose of sale.)
0 1, 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.)
0 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- ompany
0 Copy is filed with the city. 0 Certified copy is hereby furnished.
CERTIFICATE OF EXEMPiION 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 thp work for which this permit is issued, I shall not
employ angerson in any manner so as to become subject to the Workers' Compensation
Laws of Cal orn a.
DateLn__±_*1 '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 Nam
Lender's Address
This is a buildin permit when properly filled out, signed and validated, and is subject to
expiration it work I �areunder is suspended for 180 days. '
I car tify 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, Zi
No. 9626
BUILDING: TYPE CONST.—OCC. GRP.:
Number
J Description Bot 60
mt Description Plan C2
ZO NE: . BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Reaf �rop.'Lin;
Side Street Setback from Center Line
—Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
S9_ Ft.
Size .1927
No.
Stories
No. Dw.
Units
New 0 Add 0
Alter 0
Repair 0 -Demolition 0
Estimated Valuation
105,733
PERMIT
AMOUNT
Plan Chk.
Plan Chk. Bal.
552.00
Const.
660.50
Mech.
60 . 00
Electrical
114. 47
Plumbing
144.50
S.M.L.
7.42
Grading
Driveway Enc.
Infrastructure
2378.99
Arts in N-blic
25.U0
4
,T,H P6
TOTAL
9 4 2-.'B 8
REMARKS
ZO NE: . BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Reaf �rop.'Lin;
Side Street Setback from Center Line
—Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. @ $
UNITS
COLL. AREA
2ND FL SO. FT. @
Nmv/
YARD SPKLR SYSTEM
POR. SO. FT. @
MOBILEHOMESVC.
BAR SINK
GAR. SQ. FT. 0
POWER OUTLET
ROOF DRAINS
Lj-LnbEWER OR SEPTIC TANK7e, ROUGH WIRING.
DUCT WORK
DRAINAGE PIPING
CAR P. 0. FT. @
WALL SQ. Fr. @
HEATING (FINAL)
DRINKING FOUNTAIN.
SO. FT. @
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
I FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GRADING
—cu. yd.
$ plus_x$
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FINAL INSP/,q 12 Fly V
LAUNDRY TRAY
AIR HANDLING UNIT CFM
ROOFING
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEMPERM
LAVATORY
HEATING SYST�M- FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER� B.T.U.
SO. FT. a c
BATH TUB
FIREPLACE
SO. Fr. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 1 V4 c
SEWAGE DISPOSAL
SQ.FT.GAR @ V4c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
EE ELECT.FEE
SMIFEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
.0/
- GROUND PLUMBING WUNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
Nmv/
ROUGH PLUMB. BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
I it/
Lj-LnbEWER OR SEPTIC TANK7e, ROUGH WIRING.
DUCT WORK
ROCKSTORAGE
FOUND. REINF/ly
GAS(ROUGH) METER L60P
HEATING (FINAL)
OTHER APPJEOUIP.
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/,q 12 Fly V
FRAMING 0
FINAL INSP. 1
ROOFING
Teo Ori"r 0,344
REMARKS:
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
—
f
4—CAJ
LATHING
MESH
INSUILATIONISOUND
FINISH GRADING
FINAL INSPECTION -
CERT. OGC.
FENCE FINAL
INSPECTORS SIGNATURESIINITIALS
GARDEN WALL FINAL