9623 (SFD)4
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 78-645 Carries eir-le LA QUINTA, CALIFORNIA 92253
owner I
City I Zip
Contractor
State Lic. City
& Classif. B 2923954 Lic. # 1612
Arch., Engr.,-
Designer
Address Tel.
City IIJZip 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 Contractoes License Law for the following
reason: (Sec. 7031.5,Susiness and Professions Code: Any city or counly 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 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 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).
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 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-bufider wig have the burden
of proving that he did not build or improve for the purpose of safe.) -
b 1, as owner of the property, am exclusively contracting with licensed contractors to com.
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. mpany -
0 Copy is filed with the city- 0 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 46flars .($100) valuation
or less.)
I certify that in the performance of thtv work for which this permit is issued, I shall not
employ any person in any manner so as 0 become subjeiA to the Workers' Compensation
Laws of California. .,r
Date__=.__� _�,/Owneir * ., - 1, �/ . t
NOTICE TO APPLICANT. If, aftei-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 (or the performance of the
work for which this permit is issued. (Sec. 309 7, 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 aut orize representatives -of this city to enter the above-.
mentioned property for inspe2lon purposes.
Signature of applicani -Date:
Mailing Address
City, State, Zip
No. 9623
BUILDING: TYPE CONST. OCC'. GRP.�
A.P. Number
Legal Description Lot 69
Project Description P I a ri C2
ZONE:
—BY:
Minimum Setback
Distances:
Sq. Ft* 'No.
Size 19 27.
No. Dw.
Stories -Units
New 0 Add El
Alter 0 Repair 0 :Demolition 0
Side Street Setback from Center Line
—Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date—Permit
Validated by:
Estimated Valuation
105,733
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
C 552.00
Const.
660.50
Mebh.
60.00
Electrical
114. 47
Plumbing
1:44.50
S.M.I.
7.42
Grading
Driveway Enc.
Infrastructure
2378.99
krtS in PUblIC
25. U0
4
TOTAL
3942.88
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
FINAL DATE
INSPECTOR
Issued by:
Date—Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
I ST FL. SO. FT. @ $
UNITS
SLAB GRADE
2ND FL. SO. FT. @
ROUGH PLUMB. BONDING
YARD SPKLR SYSTEM
POR. SQ, FT. @
MOBILEHOMESVC.
BAR SINK
GAR. SO. FT. @
POWER OUTLET
ROOF DRAINS
CAR P. SO. FT. @
FOUND. REINF-J!/
DRAINAGE PIPING
WALL SQ. Fr. @
HEATING (FINAL)
DRINKING FOUNTAIN.
SO. FT. @
GAS (FINAL) TEMP.. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to De used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
BOND BEAM
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.1(11,flg t
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
ROOFING
LAUNDRY TRAY
AIR HANDLING UNIT CFM
REMARKS:
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.
SQ. FT. @ c
BATH TUB
SO. Fr. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR @ V4c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERM FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEt
CONST. FEE JELECT.FEE
SMIFEE PLUMB. FEE
STRUCTURE / PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR,
I
SETBACK
�"
GROUND PLUMBING UNDERGROUND
A.C. UNIT
COLL, AREA
SLAB GRADE
ROUGH PLUMB. BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
-i�SEWER OR SEPTIC TANK? I V ROUGH WIRING.
DUCT WORK
ROCKSTORAGE.
FOUND. REINF-J!/
GAS (ROUGH)/:0AVm METER LOOP
HEATING (FINAL)
OTHER . APPJEOUIP.
REINF. STEEL
GAS (FINAL) TEMP.. POLE
GROUT
WATER HEATER SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
yd.
$_plus_x$_=$
LUMBER GR.
FINAL INSP.1(11,flg t
FRAMING
FINAL INSP.
ROOFING
ce)
race
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATH!�G_M(ftlf
MESH
INSULAT . IONISOUNDIP(q/q/
FINISH GRADING
FINAL INSPECTION -
CER . OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL