13545 (BLCK)Building 48-865 Ave. Fernando
AL,Wress
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Oary Cardiff
Mailing
Address P.O. Box 1372
My Quinta, CA Zip 92253 11el _
Contractor
9;ner/Builder
Address
City lZip Tel.'
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.
i SIGNATURE DATE
OWNER -BUILDER DECLARATION
i
� I hereby affirm that I am exempt from the Contractor's License Law for the following
I 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 or 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
sub'ects the applicant to a civil penahy of not more than rive hundred dollars ($500).
I,, as owner of the property, or my employees with wages as their sole compensation, will
o the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
I Professions Code: The Contractor's License Law does not apply to an owner of property who
i 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
i 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 or property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
O 1 am exempt under Sec. B. & P.C. for this reason
.Date ' a•� i' r Owner
,r
WORKERS' COMPENSATION DECLARATION
I I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
I Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ 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 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
I aws of California. t
Date k Owner
NOTICE TO APPLICANT: If, 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.
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 stale 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. 13545
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number
,Legal Description
Project Description
60'' of 6" high
block wall
Sq. Ft.
Size
No.' -
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$1,500.00
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 Liner -
Side Setback from Proper '�Lin
tye
FINAL DATE
Issued by:—
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SETBACK
GROUND PLUMBING
UNDERGROUND
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
SLAB GRADE
ROUGH PLUMB.
BONDING
MOBILEHOME SVC.
BAR SINK
FOR. SQ. FT. ®
SEWER OR SEPTIC TANK
ROUGH WIRING
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (ROUGH)
METER LOOP
DRAINAGE PIPING
CAR P. I SO. FT. ®
REINF. STEEL
GAS (FINAL)
WALL SQ. FT. ®
DRINKING FOUNTAIN
$Q. FT. ®
WATER HEATER
URINAL
ESTIMATED CONSTRUCTION VALUATION $.
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
LUMBER GR.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
MESH
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.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM —3, -Z,�y6p
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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
'de- CA� a
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or-
LA qu,
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