9621 (SFD)Building
Address
P.O. BOX 1504
78-105 CALLE ESTADO
78-680 Carnes Circle LA QUINTA, CALIFORNIA 92253
Acac
Address '021 Basl
City Zip
Contractor ,
A6acia Construction
Address
Tel.:
State Lic. City
& Classif. B 2923954 Lic. # 1612
Arch., Engr.,
Designer
Address Tel.
City Zip State
I I Lic. If
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7DDO) 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 of counlY which requires a
permit to construct, alter, 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 rove hundred dollars (S500).
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 safe. lf, however. the budding
or improvement is sold within one year of completion, the owner -builder 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 con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
to an owner of property who builds or improves thereon, and who contracts for
rh a contractorls) licensed pursuant to the Contractor's License Law')
0 1 am exempt under Sec. -B. & P.C. for this reason
Date _____L.._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
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 dollars (S100) valuation
or less.)
I certify that in the performance of thq 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 6 - 'I, - 'J owner
NOTICE TO APPLICANT If, ifter'making this Certificate of Exemption you should becv�ne
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 building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder 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
cong4uction, and hereby authorize representatives -of this city to enter the above..
mentioned property for inspection purposes.
Signature of applicant -Date
Mailing Addres
City, State, Zip
BUILDING: TYPE CONST
P. Number
Description Loht5 4
t Description Plan B2
No. 9621
_OCC. GRP.
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:
Sq. Ft.
Size .17 2 1
No. No. Dw.
Stories Units
New 0 Add 0
Alter 0 Repair 0 -Demolition 0
Estimated Valuation
93,558
PERMIT
AMOUNT
Plan Chk. D61).
Plan Chk. Bal.
507.36
Const. .
612.50
Mech.
53.50
Electrical
103.66
Plumbing
120.50
S.M.I.
6.58
Grading
Driveway Enc.
-infrastructure
2105.06
AA;Z4_P') 4A 17&Z nX–IA-94 4
TOTAL
35019".1t6luirlL
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
IIST FL. SO. FT. @ $
UNITS
SLAB GRADE
2ND FL. SO. FT. @
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. @
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. 0
POWER OUTLET
ROOF DRAINS
CAR P. I SO. FT. @
GAS(ROUGH) /Joyl t V
DRAINAGE PIPING
WALL SO. FT. @
I
OTHER APPJEOUIP.
DRINKING FOUNTAIN,
SO. FT. @
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
IWATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
FRAMING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
Rew (�9 8114 let
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 SYST�M- FORCED GRAVITY
AMPERES SERV ENT
ISHOWER
BOILER. B.T.U.
SQ. FT. @ c
1BATH TUB
SO. FF. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ I V4 c
SEWAGE DISPOSAL
SO.FT.GAR @ 3/4c
HOUSE SEWER
I
GAS PIPING
PERMIT FEE
I PERM FEE
I PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT.FEE
SMIFEE PLUMS. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
ZGROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK7�r
ROUGH WIRING.
DUCT WORK
ROCK STORAGE.
FOUND. REINF
GAS(ROUGH) /Joyl t V
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. Lebjq I
FRAMING
FINAL INSP.
ROOFING
(gig c jq
Rew (�9 8114 let
c '0
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
1 9:21
LATHING 2 AIN 01 e.
MESH
INSULATIONISOUND Ap*
FINISH GRADING
FINAL INSPECTION -
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL