05129 (MFD5)Building
Address
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Address 777 S. Hain St., Suite 106
City Zip Tel
Grange 42656 714-547-8056
Address
Tela
State Lic. City
& Classif. 311261 LiC. # 1177
Arch., Engr.,
Designer
Address
CityI Zip I State
Lic. If
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
effect of -nasion 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. 7031.5,8usiress 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 appiicant for such permit to Me a signed statement that he is licensed pursuant to
the provisions of the Contractors License taw, Chapter 9 (commencing with Section 7000) or
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
suNects the applicant to a civilpenally of not more than rive 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, Suisness and
Professions Cade: The Contractors 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 krprovements are not intended or offered for sale. If, however, the building
or krprovement 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 safe.)
❑ 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 inproves thereon, and who contracts for
such pro)ects with a contractor(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 1 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 completed it the permit is for one hundred dollars (E100) valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, 1 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: ff. after making this Certificate of Exemption you should become
subfect 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
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 property 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. U5i29
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number 613-790-011
Legal Description
Project Description Building 36. Flan 2U. Lott 347
Sq. Ft. 912
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation.
65 2 2 5
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
9
Const.
3141 �}
Mech.
QA A
Electrical
44 76
Plumbing
� nn
S.M.I.
t; 42
Grading
Driveway Enc.
Infrastructure
I AA7q
lZrInse—T-*00
T.
38118
TOTAL
2 sal.11
REMARKS
4
f
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 II�ZZ//Sp�CST89
Issued by: Date_Permit Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
" UNITS
SLAB GRADEROUGH
PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT. @
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. 0
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SQ. FT. ®
FINAL INSP.
WALL SQ. FT.
WATER SYSTEM
DRINKING FOUNTAIN.
GRADING
cu. yd.
$ plus x$
=$
URINAL
SO FT ®
ROOFING
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING bV
MESH.
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION 7 rJ^ GJil
CERT. OCC.
ccwirc r�un� '
p
ESTIMATED CONSTRUCTION VALUATION $
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
LAUNDRYTRAY
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.
SO. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.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
Iry
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADEROUGH
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.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR. FINAL INSP. 2 CJV
FRAMING 1311 �D FINAL INSP.
ROOFING
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING bV
MESH.
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION 7 rJ^ GJil
CERT. OCC.
ccwirc r�un� '
p
REMARKS:
SIGNATURESIINITIALS
GARDEN WALL FINAL