05628 (BLCK)Building
Address 52-62.5 VELMID0
Owner Fred Black
Mailing
Address anne
City Zip
La Quanta 1 92253
Contractor
Owner/ Builder
City
State Lic.
& Classif.
Arch.; Engr.,
Designer
TaT
"
P.O. BOX 1504 N Q .
78-105 CALLE ESTADO
LA.QUINTA, CALIFORNIA 92253
BUILDING: TYPE CONST. OCC: GRP.:
- A.P. Number 773-294-01S
619/564-1995
Lic. #
City Zip • IState
C. #
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
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 Contractors License law for the following
reason: (Sec. 7031.5,Business 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 pemul to fie a signed statement that he is licensed pursuant to
Me provisions of the Contractor's license Law. Chapter 9 (commencing with Section 7000) of
Division 3 of the Bustness 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 civil penalty of not more than five hundred dollars (5500).
❑ 1, 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 Contractors License law does not appy 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 Wended or offered for safe. If, however, the building
or improvement is sod 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.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con•
struct the project. (Sec. 7044, Business and Professions Code: The Contractors License Law
does not appy to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractors License Law.)
❑ 1 am exempt under'Sec. w_ & P.C. for this reason
41, ��s
Date Owner �'' ►.,., _. -�
WORKERS' COMPENSATION DECLARATION
1 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 (5100) valuation
or less.)
I certify that in the perfomrance of thip work for which this permit is issued, I shall not
employany person in any manner so as:to become subject to the Workers' Compensation
Laws of California-
Date-Owner
aliforniaDateOwner Afv1 _'bL. s, • .j. sem.
NOTICE TO APPLICANT: ff. after makig this,'Certiticate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this pernth 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 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
05-6LV
Legal Description
Project Description BLOCK ' : 6—feet high
Peace 161 x 24' Court Yard: 'fuss 40 feet
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
stimated Valuation
$1,000.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
2.5.00
Mech.
Electrical
Plumbing
S.M.I.
+
Grading
Driveway Enc.
Infrastructure
TOTALS
„ f
REMARKS
iW62418140 04MAR-211- —k? 47 10
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 DATEINSPECTOR
Issued by: Date 4/,12/89 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT. @
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING.
MOBILEHOME SVC.
BAR SINK
POR. gQ, Ff. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEMP. POLE
I
GROUT
DRAINAGE PIPING
CARP. SQ. FT. ®
FINAL INSP.
BOND BEAM
WATER SYSTEM
DRINKING FOUNTAIN.
WALL SQ. FT.
=$
LUMBER GR.
FINAL INSP.
URINAL
SQ. FT.
ROOFING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
VENTILATION
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
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, TEM/PERM
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.
SO. FT. RESID ® 1% c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
HOUSE SEWER
CERT. OCC.
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
ME:CH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR GOND. 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 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.
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 SIGNATURES/INITIALS
t.
GARDEN WALL FINAL