05004 (RPL)T4.hf 4 4 Q"
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 10-110 ^_111— LA QUINTA, CALIFORNIA 92253
Mailing
Address -
City _ --]-Zip ITel.
Address u}ius htiai c arc aAx y A VVJ6V
State Lac_ """" ` -- ---,7` .. ' lCity w `
& Classif. 522876 Lic. # 299
Arch-, Engr-,
Designer
Address Tel.
LITy IZip I State
l Lic. #
LICENSED CONTRACTOR'S DECLARATION
I affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of an 3 of the Business arid– Professions Code, and my license is in full force and
effect
SIGNATURE- fr Wf�_.VAI.IleDATE
OWNER -BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for the following
reasort (Sec. 7031-5,Bushess and Professions Code: Any city or county which requires a
pemd to corstnc4 afar, improve, demolish, or repair any structure, prior to its issuance also
requires Use applicant for such permit to file a signed statement that he is licensed pursuant to
the provi9ors of the Contractor's license law, Chapter 9 (commencing with Section 7000) of
I)Msion 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 appicanI to a civilpenalty of not more than five hundred dollars ($500).
❑ 1, 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
bukb or improves thereon and who does such work himself or through his own employees,
provided that such I provements are not intended or offered for sale. If, however, the building
or improvement is sold wthiu one year of completion, the owner -builder will have the burden
of proving Oma1 he did not buid or improve for the purpose of sale.)
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project (Sec. 7044, Busimess 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 rfh a ahrdractor(s) licensed pursuant,to the Contractor's License Law.)
❑ 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 consentAto self -insure, or a certificate of
Workees Compensation Insurance, or a certified copy thereof. c. 3800, Labor Code.)
Policy No_ C,bmpany
❑ Copy is filed with the city. ❑ Certified copy is`hereby r mashed.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need net be completed if the permit is for one hundred dollars ($100) valuation
of less.)
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
Laws of Califomia
Date Owner
NOTICE TO APPLICANT: tl after making this Certificate of Exemption you should become
subject to the Workers' Conpansation provisions of the Labor Code, you must forthwith
coopfy with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby 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
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 100 days.
1 certify that 1 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
ateMailing Addn?ss
City, State, Tip
No. 05004
ILDING: TYPE CONST. OCC: GRP
A.P. Number 7lyti..fi12—n1E3
Legal Description
Project Description rLw
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$7,440
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
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 Line
FINAL DATE
Side Setback from Property Line
INSPECTOR
Issued by: Date 12 19 % 8Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB. Z�ING/z
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO. FT.
GAS (ROUGH)
METER LOOP
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO. FT. ®
GROUT
WATER HEATER
WALL SO. FT.
FINAL INSP.
DRINKING FOUNTAIN
SO FF ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
_$
WATER PIPING
NOTE: Not to be used as property tax valuation
FRAMING
FLOOR DRAIN
MECHANICAL FEES
}�
F
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
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.
SQ. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
INSULATION/SOUND
SO.FT.GAR @ 3/ac
HOUSE SEWER
FINISH GRADING
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
D PLUMBINC/Z-.
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB. Z�ING/z
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
ND. REINF. ,i2
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
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F
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6
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