10911 (PLBG)Building
Address
Owner
I ®
P.O. BOX 1504 N o . 10911.
7&105 CALLE ESTADO
$1O100 Gale O'ai��i0 q. LAQUINTA,CALIFORNIA92253 01
DALE BORNENBERGER
iBUILDING:-TYPECONST. OCC: GRP.
Address SAME AS ABOVE
City Zip
LA QUINTA 19225.3
BROOKS & ASSOCIATES
LA QUZNTA 1'92253 1 t
State Lic. City
& Classif. ' XXX 5 7 68 Lic. # 654
Arch., Engr.,
Designer
Address I Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION'
it hereby affirm that I am -licensed under provisions of Chapter 9 (commencing with Section
!effec
7000) of -Division 3•of-the Business and Professions Code, and my license is in full force and
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,8usiness 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 rite 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 notmore than rive hundred dollars,($500).'
O. I, 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 L.aw. 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,pnprove for the purpose of sale.) -
❑ I, as
n
owner of the property, am exclusively contracting with licensed contractors to. co-
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.) -
❑ 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, oracertified copy.thereof: (Sec. 3800, Labor Code.)
Policy No. Company '
Ah 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 the work for which this permit is issued,.) shall not
employ any person in any manner so as to become subject to the Workers' Compensation
laws of California.
Date_' Owner'
NOTICE TO APPLICANT., If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions o1 ' 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 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 authorize representatives -of this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
A.P. Number
,Legal Description
Project Description
Suer Hook Up
Sq. Ft. No. No. Dw.
Size - Stories Units
.New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation 1,000
PERMIT AMOUNT
Plan. Chk. Dep.
Plan Chk. Bal.
Const.
Mech. .
Electrical
Plumbing 30.00
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
30.00
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
IST FL. SO. FT. ® $
UNITS
COLL. AREA
2ND FL. SO. FT.
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. I SO. FT.
DUCT WORK
DRAINAGE PIPING
WALL SO. FT.
DRINKING FOUNTAIN.
SO FT ®
HEATING (FINAL)
URINAL
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
GRADING
cu. yd.
$ plus x$
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1% c
SEWAGE DISPOSAL
FIREPLACE
SO.FT.GAR ® 3/ac
HOUSE SEWER
SPARK ARRESTOR
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
G
SEWER 07MNK '
UGH WIRING.
DUCT WORK
ROCK STORAGE
FOUND. REINF.
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
d1
J
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
�/
FINAL INSPECTION- 9
CERT. OCC. ✓
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL