13799 (AR)4
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 78-735 Sa=nta Drive LA QUINTA, CALIFORNIA 92253
Owner Cary D. (see
Mailing
Address Same
City Zip Tel.
,a Quinta, CA 92253 345-2.616
Contractor
Owner/Builder
Address
Zip
State Lic.I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City (Zip (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, 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 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 penally of not more than five hundred dollars ($500).
'NpKas owner of the properly, 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 improve for the purpose of sale.)
❑ 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 for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date 1 �- j� 0 w n a
I y
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
O Copy is filed with the city. ❑ 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 ($100) valuation
or less.)
I certify that in the performance of thg workrfor 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. I/,
Date W"- Owner _(!f144 7 �.
NOTICE 'TO APPLICANT: If, `after makng this Certificate of Exemption you should become
sGbject to the Workers' Compensation provisions of the Labor Code, you must forthwith
co
ply 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 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.
it 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 authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
1
Signature of applicant Date
Mailing Address
City, State, Zip
No.
BUILDING: TYPE CONST. OCC: GRP,
A.P. Number
Legal Description
Project Description Room Addition
Sq. Ft. 2310 No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
*121,489.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
93.60
Const.
144.00
Mech.
.00
Electrical
23.05
Plumbing
0
S.M.I.
1.25
Grading
Driveway Enc.
Infrastructure
TOTAL
2 61. 9
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 'INSPEC. VO�
r /
Issued by: Date Perifiit O /
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
T' ► +`� P'
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
SEWER OR SE IC ANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEMP. POLE
GROUT 1
DRAINAGE PIPING
CAR P. SQ. FT. @
FINAL INSP.
WALL � SQ. FT.
WATER SYSTEM
FINAL INSP.
DRINKING FOUNTAIN.
GRADING
cu. yd.
$ plus x$
=$
URINAL
SQ. FT.
ROOFING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM .FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT , WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT, CFM
I
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
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 f HEATING & AIR COND. SOLAR
jp 4 aak
SETBACK ]
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.Ar
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SE IC ANK
ROUGH WIRING
DUCT WORK
ROCKSTORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL 1
GAS (FINAL)
TEMP. POLE
GROUT 1
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
FINAL INSP.
FINAL INSP.
GRADING
cu. yd.
$ plus x$
=$
I
LUMBER GR. I
FRAMING i Q
ROOFING
REMARKS:
VENTILATION
i
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULT N/SOUiND
t
FINISH GRADING
FINAL INSPECTION
CERT. OCC. 1
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
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EUlL!L?J' G & SAFEI — I DEPARTMENT
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