14775 (BLCK)Qum
P.O. BOX 1504
Building 78-495 CALLE TAMPICO
Address 78"830 Sanity Drive LA QUINTA, CALIFORNIA 92253
Owner Jim Elliott
Mailing -
Address sarae
City Zip Tel.
La Quinta 92253
Contractor
Tom Stone Masonsv
City Zip Tel.:
La Quinta 92253 564-2128
State Lic. City
& Classif. 894257 Lic. # 1228
Arch., Engr., I
Designer
Address I Tel.
City (Zip (State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am Ircensed under provisions of Chapter 9 (commencing with Section
y/7000) of Division 3 of the Business and Professions Code, and my license is in full force and
�
tF effect.,j -2 -L F r
SIGNATURE DATE
OWNEWBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: _ (Sec. 7031.5,Bushess 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 file a signed statement that he is licensed pursuant to
the provisions or 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 or Section 7031.5 by 'any applicant for a permit
subjects the applicant We civil penalty 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, auisness 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 improve for the purpose of sale.)
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044,• Business and •Professions Coder 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) ffcensed 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 acertificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
X Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(This section need not be completed it the permit is forone hundred dollars ($100) valuation
or less.)
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 subjectto the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT. h, 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.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES As PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
This'is a building permit when property 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 stale that the above. information is correct.
1 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
No. 14775
BUILDING: TYPE CONST. . OCC: GRP.
Number
Legal Description
Project Description 80 if of $ t garden Wali
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation $2,000.00
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const. 45.00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
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
111
Permit-� rt
L\
Validated by:
�
Validation:
I
FR F - 2ME;
v
S
i By-
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
PLUMBIW—,EES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
2ND FL. SO. FT.
BONDING
YARD SPKLR SYSTEM
F
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET,
ROOF DRAINS
CAR P. I SO. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SO. FT.
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
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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.
SO. FT. ® c
BATH TUB
SPARK ARRESTOR
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1'A c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/4c
HOUSE SEWER
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
FOUND. REINF.AA
GAS (ROUGH)
METER LOOP
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.
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
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