11877 (BLCK)_N • ��
-ti
4
P.O. BOX 1504
Buildingrte. 640l•�3irti 78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Mailing
Address 94-940 Hwy 111r Ste. 429
,;e -'City Zip Tel.
Indian Wells 1 92210 1.564-6929
Contractor
Sam
Address
City IZip ITel.
State Lic. ( City 2419
& Classif. Lic. #
Arch., Engr-.,
Designer
Address Tel.
City I
Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that,l am licensed under provisions,of Chaptei-9 (commencing with Section
70 0) Division 3 of•the Business and Profession's Code, an8-my licen'sre is in full force and
!effect.
_SIGNATURE - DATE
OWNER -BUILDER DECLARATION
I 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, after, 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 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 not more than five hundred dollars ($500).
❑ 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 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 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 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
Q.
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, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy.yd" Company
opy 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 ihp work for which this permit is issued, I shall not
employ any person in any mannerso as to become subject to -the Work'rs',Compensation
ItLaws of California. a j
j ! � F/
Date Owner fG +: +fit.f .rY sf 3 SPY .
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 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
No. 11877
BUILDING: TYPE CONST. OCC: GRP.:
.P. Number
Legal Description
Project Description 60'
. 80'
of 6' high block wail
of 5' high block -wall
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ '° Demolition ❑
Estimated Valuation $3,232.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
63.00
Mech.
,
Electrical
v
Plumbing
'
S.M.I.
M 40
Grading
Driveway Enc.
Infrastructure
r
TOTAL
63.40
REMARKS
-r
4� n
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date k Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FES$'
1ST FL. SO. FT. ® $
w
2ND FL. SO. FT. @
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. SO. FT.
WALL SO. FT.
SO. FT. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APP./EOUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
"TEMP. POLE
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.
SO. FT. ® c
BATH TUB
SO. 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
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
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE r
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINIV,f,
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EOUIP.
REINF. STEEL
GAS (FINAL)
"TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND 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 SIGNATURES/INITIALS
GARDEN WALL FINAL
Building
Address ;�5� �/� / �,`?i/
(f�`�' 1/!d
P.O. BOX 1504
78-105 CALLE ESTADO
O LA QUINTA, CALIFORNIA 92253
- - SS�itJiP. cJ, LG�t'�'
Mailing7.
Address !/ V
City Zip Tel.
W, ... 9221 a 5-6 4/- 692
Contractor _,gde's I
Address .
Tel.
State Lic. I I City
& Classif. Lic. #
"Arch., Engr.,
Designer
Address Tel.
City( Zip I
State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisiotls of Chapter 9 (commencing with Section
7000) of Division 31 -of -the Bu siness a d Professions Code, rid"myr tic se is in full force and
effect.
SIGNATURE +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 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 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 not more than five hundred dollars ($500).
I] 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 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 did not build or improve for the purpose of sale.)
1-1 1, 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 of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
171 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' C Comp sa ion . s r V; or a certifi c gylChe�eg(, (Sec. 3800, Labor Code.)
Policy p?npany C JfC,[J
173 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 if the permit is for one hundred dollars ($100) valuation
or less.)
1 certify that in the performance of thg work for which this pfl it is issued, I shall not
employ any person in any manner,sgas to becorrle subject to . e Worjce s' Comp nsation
Laws of California. J(\\\/j
Date Owner
NOTICE TO APPLICANT: If, a ter ma mg this Certificate or 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 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
BUILDING DIVISION
7
APPLICAONLY
.7r*-.
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number tJ y '!
Legal Description L.. 6 7- A? /Z
Project Description
•.rY 4—
Sq. Ft. No. No. Dw.
Size Stories Units..
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT r f AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical f
Plumbing !! ;
S.M.I. /
Grading
Driveway Enc. t
Infrastructure 1
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback fror Rear Prop. Line
Side Street Setbcck from Center Line
Side Setback from Property Line
FINAL DATE tkISPECTOR
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. n $
2ND FL, SQ. FT, @
POR. SQ. FT. @
GAR. SO. FT. @
CAR P. SO. FT. p
WALL SO. FT. ¢
SO. FT. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
'
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAIMAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
SLAB GRADE
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
SEWER OR SEPTIC TANK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
DUCT WORK
LAUNDRY TRAY
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.
SO. FT. @ c
BATH TUB
GROUT
SO. FT. p c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID p 11A c
SEWAGE DISPOSAL
SO.FT.GAR @ 3/aC
HOUSE SEWER
WATER SYSTEM
GAS PIPING
PERMIT FEE
LUMBER GR.
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. REIN
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
REINF. STE
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP,
BOND BEAM �a
((((
L
WATER SYSTEM
GRADING
CU. yd.
$ plus x$
_$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
r
/
_ "C �/ /
S [ `
I
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