003629 (BLCK)T4 hf
P.O. BOX 1504 No: 003629
78-105 CALLE ESTADO
Address 54-145 Avenida VelaSCO LA QUINTA,.CALIFORNIA 92253
Owner _
martin G. Peterson - BUILDING -TYPE -CONST.
MailingOCC'IGRP.
Address O € ^-w 71; 14 A.P. Number, 774-212-418.
CityJZip Tel. }
" n2llf 3 . .64 Legal Description
ContractorProject Description 3 ���� � 0011 SI�cted
.Ch ner/BUilder ^ _ _ _
Address .. w On ""fth And st®lath nidap . of vnrbinexty •
Total .f00tarxa 80 . feet 6.: h.�oh .
City'. .. .T_
Zip. _
Tela.
_
State Lic.
City
& Classif.
Lic. #
Sq. Ft.
No. No. Dw.
Size-
Stories Units
•
Arch., Engr.; ...... _ .. _ .. .. .
Designer"
New ❑ Add ❑
Alter ❑- .. Repair ❑ Demolition ❑
Address
Tel.
City
Zip
State
Lic. # _
LICENSED CONTRACTOR'S DECLARATION
I hereby 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. ...
DATE
_SIGNATURE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following.�g
reason. (Sec. 7031.5,Business and Professions Code: Any. city or county which requires a
Estimated ValUatlOn .
0.00
PERMIT
,
•.. ' - AMOUNT' r "
-
permit to constrict• alter, improve, demolish,.or repair anystructure, prior to its issuance also
requires the applicant for such permit to rile.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, 0i 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 ($500).
O I, as owner of the property, ormy 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
' -Plan Chk. bep.
-
- •
Plan CFik.' Bal.
COnst.
ryi ti i `Y 3
•
Mech.
'
: 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 improvement is sold within one year of completion, the owner -builder will have the burden
or proving that he did not build or improve for the purpose of.sale.)
Electrical
..
- - - • • -
-
Plumbing
' O 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
S.M.I.'
_
such projects with a.contractor(s) licensed pursuant to the Contractor's License Law.) -
O I am exempt under Sec.- B. & P.C. for this reason
,i
Grading
Driveway Enc.
Date �� 4-A- Owner
Infrastructure
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.. _ O Certified copy is hereby furnished.' _
TOTAL
CERTIFICATE OF EXEMPTION FROM
WORKERS'. COMPENSATION INSURANCE
REMARKS-,
,
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)a�i:,
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any person in- any manner sous to become�subject'to the Workers' Compensation.
Laws of California.
k Sea.
> g 3 baFr �tt;p,_y. �T
' 'Date Owner
NOTICE TO APPLICANT:. If, after making this Certificate of Exemption you should become
subject 'to the' Workers" Compensation provisions of -the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked. -
ZONE: ' BY:
Minimum Setback Distances: -
Front .Setback from Center Line
Rear Setback from Rear Prop., Line
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.) •.
Side Street Setback from Center Line
Side Setback from Property Line
Lender's .Name
FINAL.DATE
Issued by:
Valldated,by:
INSPECTOR
b /ct Permit
Date 1 y
R
Lender's 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 car lity 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.
Validation:
City, State, Zip
HARD COPY
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
2ND FL. SQ. FT.
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. SO. FT.
WALL SO. FT. ®
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
I ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
I
IKITCHEN 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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/a c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
REMARKS:
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
NIECH.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.
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.
GARDEN WALL FINAL