05118 (MFD5)T4ht 4 4 Q"
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 76-219 Criason Drive LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address 777 S. Main St. , Suite 201
City Zip Tel.
f�txirroa 414!W4
Contractor
City
State Lic. City
& Classif. 311261 Lic. # 1177
Arch., Engr.,
Designer
Address Tel.
City izipState
I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
700 of Division 3 of the Business and Professions Code, and my license is in full force and
effect f
SIGNATURE DATE
r OWNEWBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Busness 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 penrrd 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 aleged exemption. Any violation of Section 7031.5 by Any applicant for a permit
subjects the applicant to a civilpenally 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 wok, and the structure is not intended or offered for sale. (Sec. 7044, Suisness 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 rmprovermlents are not intended or offered for sale. 11, however, the building
or improvement is sok/ 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, 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 contacts 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
Date net
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' COMPENSATION INSURANCE
(This section need not be conpleted if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thq 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 California
Date Owner
NOTICE TO APPLICANT: 9, after making this Certificate of Exemption you should become
subject to the Mrkers' 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.)
Lenders Name
Lenders 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. 05118
ILDING: TYPE CONST. OCC: GRP.
I. Number 613-790-011
Description
;t Description Building 36, Plan 1, Lot 354
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 .2128/8 Permit
Validated by:
Validation:
Sq. Ft. 926
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
l 4 t
$yr�i6, 731
PERMIT
AMOUNT
Plan Chk: Dep.
Plan Chk. Bal.117l
Const.
14 q4 n
Mech.
no
Electrical
tiS OA
Plumbing
75 in n.
S.M.I.
Grading
Driveway Enc.
Infrastructure
[�
ft ry^_
F- =-rA
A
TOTAL
REMARKS
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 .2128/8 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
PLUMBING FEES
IST FL SQ. FT. ® $
UNITS
COLL. AREA
SLAB GRADE I
Q
YARD SPKLR SYSTEM
E
2ND FL SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SO. FT, ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. ®
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
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 ® t+A c
SEWAGE DISPOSAL
SO.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 PLUMBINCy ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
40
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE I
Q
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
00�SEWER
OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF. J
Lim %
LC/
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM WATER SYSTEM
LUMBER GR. FINAL INSP.
Olf
FRAMING l 0 FINAL INSP.
ROOFING
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND ` O
FINISH GRADING
FINAL INSPECTION W �J � �
CERT. OCC.
FENCE FINAL
GARDEN WALL FINAL
GRADING
cu. yd.
$ plus x$ _$