05139 (MFD5)P.O. BOX 1504
Building 7&105 CALLE ESTADO
AddreSs6-207 E'rim4no fl a LA QUINTA, CALIFORNIA 92253
Owner '
Mailing
Address 7-77 S. Main St Suite 106
City Zip Tel.
0418 RC 1 92686 1 7(6--07-8056
Contractor
Address
Tela
State Lic.I City
& Classif. w .. „.. Lic. #
Arch., Engr.,• I
Designer
Address I Tel.
City( Zip ( State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
700(1) of Division 3 of the Business and Professions Code, and my license is in full force and
effect i' -
SIGNATURE- f •� •" 1r + •. �. , - -- DATE
r j " OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,8uskness and Professions Code: Any city or county which requires a
permit to construct, after, igprove, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to We 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 civilpenally 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 hwrovement is sold within one year of completion, the owner -budder will have the burden
or 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. R. & 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
Workers 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 completed if the permit is for one hundred dollars ($100) valuation
or less.)
I 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 California.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the workers' Conpensation 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
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.
1 certity 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 Address
City, State, Zip
LDING: TYPE CONST
No.
OCC: GRP.
P. Number 613-74n-011
05139
Legal Description
Project Description 1111xftr34no 4A- FiA" 4T._ T^*, 14A
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
12/28/88
Issued by: Date Permit
Validated by:
Validation:
Sq. Ft.
Size: 763
No.
Stories
No. Dw.
Units.
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
�YY
Estimated Valuationr�6s66
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
$ 251.81
Const.
304.00
Mech.
33.00
Electrical
41.78
Plumbing
63 . oO
S.M.I.
3,96
Grading
Driveway Enc.
Infrastructure
1,279.94
Frinsrevp`F QQ
.:is�rtrd
3f3. �$
TOTAL
92.015.67
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
12/28/88
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE ®
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT. @
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SO. Fr. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO. FT.
GROUT
WATER HEATER
WALL SO. FT.
FINAL INSP.
DRINKING FOUNTAIN.
BOND BEAM
WATER SYSTEM
URINAL
SO FT ®
=$
LUMBER GR.
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP. Z (y 9(�
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
VENTILATION
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIRE ZONE ROOFING
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FIREPLACE
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.
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 ® 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 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. j a (��
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. Z (y 9(�
FRAMING 344 9/v
FINAL INSP.
ROOFING
, 'a
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING 016jam
MESH
INSULATIONISOUND
FINISH GRADING
i
FINAL INSPECTION`S
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
l