13924 (PLBG)4
I '
P.O. BOX 1504 No, 13924
Building 51- 775 Ave. corte:z 7&105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Owner <
Jeiri22e M. Rcsys
BUILDING: TYPE CONST. OCC: GRP. -
Mailing Same
Address
City Zip Tel.
La Quinta, CP, 12253
Contractor
Owner/Builder
Address
Zip I Tel.
State Lic.I Gity
& Classif. Lic. #
-Arcn., tngr., — - —
Designer
Address Tel.
City r Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
i 7000) of Division 3 of the Business and Professions Code, and my license 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 or 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
subjec�.the applicant to a civil penalty or not more than five hundred dollars ($500).
❑ ,, 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 or 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
2a 4� 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 No. Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(This section need not be completed i1 the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work for which this permit-tissued, I shall not
employ any person in any minrar so as to become subject to the Workers' Compensation
LatesoeCflIwrier r7
�a✓-+:.��
NOTICE tTO APPLICANT: If, f after making this Certificate of Exemptionyou tshould 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
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.)
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 sof this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
A.P. Number
Legal Description
Project Description Sewer Connect
Sq. Ft. No. No. Dw.
Size- Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ 'Demolition ❑
Estimated Valuation slr000.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
30.00
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
30.00
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line`s
r,
Side Street Setback from Center)ine�
Side Setback from Property, Line e
FINAL DATE
Issued by:
Validated by:
Validation:
T •
INSPECTQ_fffI
Armit 1
-< 94 i
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SQ. FT. @
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. p
I POWER OUTLET
ROOF DRAINS
METER LOOP
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SQ. FT.
GAS (FINAL)
WALL SQ. FT.
DRINKING FOUNTAIN
SQ. FT. ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
GRADING
cu. yd.
$ plus x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR @ 3/ac
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
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
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
R/
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
I N SU LATI ONISOU N D
FINISH GRADING
FINAL INSPECTION
CERT. OCC. L
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
-
GARDEN WALL FINAL
'
s;
CASH RECEIPT DETAIL
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Received From: ` �� >-4, / C 1-,? Lk,% 7 7 -, > G -/)
Address: %j �1
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Service Address
❑ Meter(s)
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❑ Service(s)
❑ Backflow(s)
Check �
Money
Order
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❑ House Lateral(s)
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Cashier 1
❑ DetectorCheck(s)
O Meter Surcharge
C>(Senitatlon Capacity Charge
e
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Tum onCharpA
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment- A.D.- Bond
Assmt.
O Customer Deposit
❑ Other
Remarks:
G.A. Code
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K:, t^S' I
ted
TOTAL t
C3 copy to:
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WaterService
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Money
Order
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