04331 (BLCK)4 0
4 %'21
P.O. BOX 1504
Building S4-4 70 AMIDA . t ea 78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Owner
Mailing
ST T UM MSTRUM'4014 CO BUILDING: TYPE CONST. OCC. GRP.
Address P.O, BOX 5..374 A.P. Number WHIMM 774-233-011 012
CityZip Tel.
LA Q TA 9225 564-701 Legal Description
Contractor Project Description 1=401UG WALL
Address 1100. $O$ 807
City 1'i'
Tel.
92276 343-2672
State Lic. City
& Classif. B-1 469157 Lic. # 1114 Sq. Ft. No. No. Dw.
Arch., Engr., Size Stories Units
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel. 1000 OF 2 P=
City Zip ', State 100' 01 k FOOT "
E Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division -3 the Business and Professions Cod_e,,and my license is in full force and
effect'..
SIGNATURE.•'--'�--*•-�• % - DATE
`OWNER -BUILDER DECLARATION
Estimated Valuation
I hereby affirm that I am exempt from the Contractor's License Law for the following , 332
reason: (Sec. -7031.5. Business and Professions Code: Any city or county which requires a i -
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 PERMIT AMOUNT
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 Plan Chk. Dep.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
0 1, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const.
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, Mech.
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 Electrical
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- Plumbing
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 S•M.l. �(
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
O I am exempt under Sec. B. 8 P.C. for this reason Grading
Driveway Enc.
Date owner 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 thereoL (Sec. 3800, Labor Code.)
Policy NO. .Company
❑ Copy is filed with the city. 0 Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation #;rye}T{ { -0 A ('Mr 474) 1 -"PR �� �;� j I
or less.)
I certify that in the performance of thg work for which this permit is issued, 1 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 - ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances:
comply with such provisions or this permit shall be deemed revoked.
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 performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.) Side Setback from Property Line
Lender's Name
Lender's Address FINAL DATE INSPECTOR
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. 7/21/68 121/68
1 certify that I have read this application and state that the above information is correct. Issued by: Date Permit
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:
City, State, Zip
1
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE �+
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES '
IST FL SO FT rp S
UNITS
SLAB GRADE
ROUGH PLUMB
BONDING
YARD SPKLR SYSTEM
2ND FL SO FT. a
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR SO FT. Qr
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR SO. FT. Qr
TEMP. POLE
GROUT
DRAINAGE PIPING
CARP. SO FT. 8
FINAL INSP.
WALL SO. FT. @
WATER SYSTEM
DRINKING FOUNTAIN
GRADING
CU. yd.
$ plus xE
=$
URINAL
SO. FT. 0
FINAL INSP.
FRAMING
ESTIMATED CONSTRUCTION VALUATION S
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(AUTONDISHI
APPLIANCE DRYER
FIRE ZONE ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIREPLACE
ILAUNDRYTRAY
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.
SQ. FT. RESID tai. c
SEWAGE DISPOSAL
SO.FT.GAR rg 3/4c
HOUSE SEWER
FINAL INSPECTION
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 8 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 APP.IEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
CU. yd.
$ plus xE
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
/�� G li
ROOFING / �! Q
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 7d