04993 (BLCK)P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 54-470 Juarez LA QUINTA, CALIFORNIA 92253
Mailing '
Address P. 0. Box 1379
City Zip Tel.
La ftrota 92253 5&4---7411
Contractor
State Lic. City
& Classif. 469157 Lic. # 1 114
Arch., Engr.,• .
Designer
Address Tel.
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
70pp) of Division 3of the Business and Professions Code, and my license is in,full force and
effect. i � .�'•�' _....--.,x 1��_..-��
SZGNATURE �� 1 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 Processions Code: Any City or county which requires a
Permit to construct, after. Improve, demofsh, or repair any structure, pdor to Its issuance also
requires the applicant for such permit to Me a signed statement that he is licensed pursuant to
the provisions or the Contractors License law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Processions 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 than five 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
Processions Code: The Contractor's license Law does not appy to an owner of property who
bKd1ds 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. ft, however, the building
or improvement is sold within one year of completion, the owner -budder will have the burden
or proving that he did not build or improve for the purpose or safe.)
❑ I, as owner of the property; am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, BusinessandProfessions Code: The Contractor's License Law
does not appy to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) fcensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. A a. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, labor Code.)
Policy No. Company
❑ Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it 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 sdbject to the Workers' Compensation
Laws of California
Date` Owner Jee {, y
NOTICE TO APPLICANT: If, after makiq°"this Cerhfcate of Exemption you should become
subject to the Workers' Compensatfon+"provisidns of the Labor Code, you must forthwith
comply with such provisions or this pemtit 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.)
Lenders Name
Lenders Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it 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 appficant Date
Mailing Address
City, State, Zip
No. 04993
BUILDING: TYPE CONST.. - OCC: GRP.
A.P. Number 774-"233-0111012
Legal Description
Project Description .
130' 'D� 5'
'hieb vadden urn -11
Sq. Ft.
Size
No.
Stories - '
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
L
Estimated Valuation
$3,250
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
144.50
Mech.
Electrical
Plumbing
S.M.I.
n
Grading
Driveway Enc.
Infrastructure
ff
TOTAL
Af ex -0
REMARKS
V
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
12t13/8R
Issued by: Date Permit
Validated by:_
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES '
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT. @
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SQ. Fr. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SQ. FT.
GROUT
WATER HEATER
WALL SQ. FT.
FINAL INSP.
DRINKING FOUNTAIN
Zq6DND BEAM - 3 '
WATER SYSTEM
URINAL
SQ FT ®
=$
LUMBER GR.
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUlTOXDISH)
APPLIANCE DRYER
VENTILATION
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIRE ZONE ROOFING
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FIREPLACE
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 ® V4c
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 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
ROCKSTORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
Zq6DND BEAM - 3 '
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 SIGNATURESIINITIALS
GARDEN WALL FINAL
1