002524 (BLCK)4
P.O. BOX 1504 N o .
Building 51-205 LA QUINTA, CALIFORNIA 92253
Address -
Owner
Ben. ��'1
Mailing
Address
City Zip Tel.
ba a3
Contractor
Address
002524
BUILDING: TYPE CONST. OCC: GRP."
A.P. Number 76Q-112 -MR
Legal Description Tt*- 4A
Project Description "
City ..
Zip
Tel.. _.
State Lic-
City
& Classif.
Lic. #
Sq. Ft:
No. No. Dw.
Size
Stories • Units
Arch., Engr:, . .
Designer
New d Add ❑
Alter ❑ Repair ❑ Demolition ❑
Address
Tel.
+y�j
t3 14t7t.
i\.s Ofdbain 83d* fez=, Cixler�
bV pl�.9 ta'� F -A11 be playnted- prior to
City
Zip
State
Lic. #
f
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions; of Chapter 9 (commencing with'Section
7000) t.of Division 3 of the Business and Professions Code, and my license is in full force and
effec... .. .. - ..
SIGNATURE DATE
OWNER -BUILDER DECLARATION
hereby affirm that I am exempt from the Contractors 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
permit
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 B&isiness •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 thawfive hundred dollars.($500). —
' O 1, as owner of the. property, or my employees with wages,as.their sole compensation,,wiII
do the work, and the structure is not intended or offered forsale. (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 dM not build or Inprove, for the purpose of sale.) - -
Estimated Valuation
s �� GO
-
PERMIT
-
- AMOUNT
'
-
Plan Chk. Dep.
Plan . Chk. Bal.
-.17.22
Const..
9 .�v
' Mech.
."
"Electrical -
-
Plumbing
• -
❑ l,, as owner of the property, am exclusively contracting with licensed contractors lo'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.)
111 am exempt under Sec.. B. & P.C. for this reason
-
Grading
Driveway Enc.
Date Owner n
Infrastructure
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. 9800, Labor Code.)
Policy No. Company
O Copy is filed with the city. O Certified copy is hereby furnished.
TOTAL
44.22
REMARKS
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 the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to'theWorkers' Compensation
Laws of California.
' Date__' 'Owner
NOTICE TO APPLICANT.- ' ft, 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. ' "'
ZONE: BY: '
Minimum Setback Distances: '
Front Setback from Center Line"
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Side Street Setback from Center Line '
I hereby affirm that there is a construction lending agency for the performanceof the,
work for which this permit is issued. (Sec. 3097, Civil Code.) -
Side Setback from Property Line '
Lenders Name
Lenders Address
FINAL DATE
Issued by:
INSPECTOR
�G C
Date -gtnJ permit
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 certity 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.
Validated by:
Signature of applicant +: Date
Mailing Address , _ -
Validation:
A6138
8 6 44.22 U
City, State, Zip
HARD COPY
} CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. i SQ. FT. ® $
2ND FL. � SQ. FT.
POR. SO. FT. ®
GAR. SQ. FT. ®
CAR P. SQ. FT.
WALL +I SQ. FT. ®
i SQ. FT. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWE O TL T
J
YARD SPKLR SYSTEM
BAR SINK s
ROOF DRAINS
DRAINAGE PIPING
- DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS l
WATER SOFTENER
VENT SYSTEM FAN I EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
KITCHEN SINK
ABSORPTION SYSTEM. B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ® c
BATH TUB
I
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
REMARKS:
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 l
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE I
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS l
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
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 I
FIRE ZONE ROOFING!
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
s
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
I}
FENCE -FINAL. L
INSPEGIUK'S SIGNAIUKt511N111ALS
GARDEN WALL FINAL`