15833 (BLCK)P.O. BOX 1504 N o . 158-33
Building 78-495 CALLE TAMPICO
Address 59--820 Neetareo LA OUINTA, CALIFORNIA 92253
Owner Clinton Cogbxll.1
BUILDING: TYPE CONST. OCC: GRP.
Mailing
Address c/o P.O. Box 376 A.P. Number
.City Zip Tel.
Callraesa, CA - 92320 ( Legal Description
Contractor Project Description 130 l . f . of 6' high garden.
83.W. Simmons, Inc. wall
1025 Callzi4sa Bled. #S
Cit Zip TI.:
a l a, CA 92320 (909) 795-8928
State Lia 35995 City 336?
& Classif.. Lic. #
Arch., Engr.,
Designer
Address Tel.
City Zip State
Lic. #
.r i . LICENSED CONTRACTOR'S DECLARATION
I hereby affiA that I am licensed underrprovisions of Chapter..9.(commencing•with•Section
7000) of Division'3`of'tfie Business Sti-Professions=Code, and my licenseAs4n.full force and
/
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, atter, 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's contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. IB. & 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
Worker's
mpensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy Company
-.E-F'copy Is filed with the city. 1 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 the work for which this permit is issued,,l 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. 'd, 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. -
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
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. '
Icertify that I have read this applicatiownd state Ahat 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
REMARKS
ZONE: BY:
Minimum Setback Distances: !
Front Setback frd/ en Line
Rear Setback f� earrP�P °°I ine
Side Street S ck fro r?ter e
Side SetbaWfromerty Line /,\\
FINAL DA
Issued by
Validated
[ Validatior
Sq. Ft.
Size
No.
Stories
No. Dw.
Units -
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated, Valuation3
PERMIT
AMOUNT
Plan Chk. Dep. .
Plan Chk. Bal.
Const.
F5. (50
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
54. 00
REMARKS
ZONE: BY:
Minimum Setback Distances: !
Front Setback frd/ en Line
Rear Setback f� earrP�P °°I ine
Side Street S ck fro r?ter e
Side SetbaWfromerty Line /,\\
FINAL DA
Issued by
Validated
[ Validatior
1 ' . CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING. FEES
1ST FLL.. SQ. FT. ® $
2ND FL.e SQ. FT. ®
POR. SQ. FT. ®
GAR. SO. FT. ®
CAR P. SQ. 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
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRYTRAY
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 ® 3/4c
HOUSE SEWER
REMARKS:
VENTILATION
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.
W-80ND BEAM - [ OI
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
INSULATIONISOUND
FINISH GRADING
00"FINAI- INSPECTIOez--��"
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL