04353 (SATT)Building
Address '
Owner
Mailing
Address
City
Palm
Contractor
Address
City
State Lic.
& Classif.
Arch., Engr.,
Designer
Address
ft ise
75-005 CK
Zip
National
Sam
208,130
• - III�/� vim` i
P.O. BOX 1504 ,
78-105 CALLE ESTADO
.,LA ;O UINTA;�CALIFORNIA,92253 '
" BUILDING:- TYPE CONST. OCC. GRP.
'01lu 3 Dries A.P. Number oPAl, Woctla' . P drea'!��•c��,s►et�
Tel.
Legal Description Vin,
Project Description T161, WR -► Mmse `1G -
Tel.
City
Lic. # 39 Y : $q. Ft.. , , . �► No.., -
Size Stories'
Tel.
City Zip State
- Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
<'t 7000) of Division 3 of the Business and Professions Code, and my license is.in full force and
effect.,.,' i.,�`. �' ✓ s° •: !) ' tyi /�
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
New ❑ Add ❑ Alter ❑
Estimated Valuation $95to217
w.
No. Dw.
Units
ReDalr ❑ k,Demolition ❑
x.
•
-
AMOUNT, '
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) or
s
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for, Any Section 7031.5 for
Plan Chk. Dep.
the alleged exemption. violation of by. any applicant a permit
subjects the applicant to a civil penalty of not more than rive hundred dollars ($500).
Plan Chk. Bal.
-
:,�+ �,5
¢
., 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
PERMIT
-
AMOUNT, '
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) or
s
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for, Any Section 7031.5 for
Plan Chk. Dep.
the alleged exemption. violation of by. any applicant a permit
subjects the applicant to a civil penalty of not more than rive hundred dollars ($500).
Plan Chk. Bal.
-
:,�+ �,5
¢
❑ 1, as owner of the property, or my employees with wages as their sole compensation, will
. .
do the work, and the structure is hot intended or offered for sale. (Sec. 7044, Buisness and
Const.
R+, sf
00.
Professions Code: The Contractor's License Law does not apply to an owner of property who
_ g'1 a
builds or improves thereon and who does such work himself or through his own employees,
Mech.
--! �f
provided that such improvements are not Intended or offered for sale. If, however, the building
«9{
- .'00.
• or improvement is .sold within one year of completion, the owner -builder will have the burden
Electrical
-..;.+v
of proving that he did not build or improve for the purpose of sale.)
o
' ❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-.
Plumbing
- r.J ,"jai 9,00
struct the project. (Sec. 7044,- Business and Professions Code: The Contractor's License Law
does not to of who builds or improves thereon, and who contracts for
S.M.I.
apply an owner property
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
Grading
•
❑ 1 am exempt under Sec. B. & P.C. for this reason
Driveway Enc.
"
Date owner
Infrastructure
�2 # 142.39
'
�s._,Credit. 1,071#20 _
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
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
— 1'
v
TOTAL
vy o a 410
r
CERTIFICATE OF EXEMPTION FROM
REMARKS
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
t saAtSq�1 y tit
�•t"-^` �'?+ �9f�4'37`T fir i' ` 1 °"¢F��';�i -A A
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
ZONE:
• BY:
subject to the. workers= Compensation provisions of the .Labor Code, you must forthwith
comply with such_ provisions or permit shall be deemed revoked.';
Minimum Setback Distances: -
- 1-
-this
'
Frtirit Setback from Center Line
n
Rear.Setback from Rear Prop. Line
= CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the '
Side Street Setback from Center Line
.work for which this permit is issued.' (Sec. 3097, Civil Code.)
Side Setback from Property Line
' Lender's. Name
`Lender's Address. ,, • _ ... •� -_
This is a building permit when properly filled out; signed and validated, and.is subject to
-
FINAL DATE
SPE0T `
asj J3OR
expiration If work thereunder is suspended for 180 days.
- -
' I car Illy that I have read this application and state that the above information is correct..
Issued by:
- -Date Permit
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
t mentioned property for inspection purposes..
Validated by:
Signature of applicant Date
s
' %
Mailing Address
Validation:
City, State, Zip
WHITE -FINANCE, PINK AP 4,.
APPLICANT, GREEN- BUILDING; GOLDENROD -ASSESSOR'S OFFICE,"HARD COPY --.FILE'
.ei. ..-. .. ... 1�<.. w.--_- _. -... c-
._ .. ,rd -a•_ ..-.a
.,.. .. -..-1.-. .. s. ....5-.�-'. r.Y_�. _. •!'4 .. .f.. -� tk. r.'
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IS7 FL SO F7 rp S
UNITS
SLAB GRADE
ROUGH PLUMB
BONDING
YARD SPKLR SYSTEM
2ND FL SO FT. a
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR SO FT of
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR SO. FT. Or
TEMP. POLE
GROUT
DRAINAGE PIPING
CARP. SO FT. �
FINAL INSP.
BOND BEAM
WATER SYSTEM
DRINKING FOUNTAIN
WALL SO. FT. (V
_$
LUMBER GR.
FINAL INSP.
URINAL
SD. FT. 43
ROOFING
ESTIMATED CONSTRUCTION VALUATION S
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
I
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTONDISH)
APPLIANCE DRYER
FIREPLACE
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT. B.T.U.
SO. FT. RESID @ 1% c
SEWAGE DISPOSAL
SO.FT.GAR @ >r:c
HOUSE SEWER
GAS PIPING
PERMI7 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 8 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.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEOUIP.
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
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR,
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATIitESlINITIALS
GARDEN WALL FINAL