15018 (ELEC)4
1504
Building 78-110 Calle Tampico 78-49P.O. BOX 5 CALLE TAMAMPICO
Address LA QUINTA, CALIFORNIA 92253
Owner The Circle K Corp.
Mailing
Address Swire
City Tel.
La Quinta, CT-AZjp
92253 564-1042
Contractor
Michael, A. Estabr®ck
Address
.22882 Caminito Flores
City ' Zip TV.:
�agura Hills, CA 92653 714)$30-8175
State Lic. City
& Classif.. 507948 Lic. #
Arch.,'Engr.,
Designer
Address Tel
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
�t ! ri f
I her by affirm #rat I am liven=.under provisions of Chapter 9 (commencing with Section
000) of Division 3fof the Busines�s'and•Professions Code, and my license is in full force and
ffact t? -7Ir`i 3
31IGNATURE DATE
_ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec.. 7031.5,8usiness and Professions Code:. Any city or county which requires a
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
the provisions of the Contractor's License Law, Chapter9 (commencing with Section 7000) -of
Divlslon 3 of the Business and -professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any vkNation or Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civr7 penalty 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, Suisness 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 improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or knprove 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 B. & 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
WorkePs Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city,. O 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.) e
I certifythat in the p { A
performance gr, the work�forNCvh•c 'this permit is issued, I shall not
employ any person in any rpanner's as to becom R subjecf to the Workers' Compensation
Laws of Cali o ma t
Date 4' fele' Owner r�
OT/CE TO APPLICANT: It, after making this Certificate of Exemption you -should -become -
subject to the Workers' CmWensat)on provisions of the Labor Code, you must forthwith' •
comply with such provisions or this permit shall be deemed revoked. '
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE; INTEREST, AND
ATTORNEY'S FEES.
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read thisapplication and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relatingto 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. 15018
BUILDING: TYPE CONST. OCC: GRP.
Number
Legal Description
Project Description Install One_ 29 amp 220q
dedicated circuit
ZONE: .;-BY:
Minimum'Se_tback Distances:
Front Setback`gom Center Line d
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
- Validation:
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑ .'
Estimated Valuation
.$1.00.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const:
Mech.
Electrical
J 71 5
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTALt
5 ' ° a
REMARKS
``.
ZONE: .;-BY:
Minimum'Se_tback Distances:
Front Setback`gom Center Line d
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
- Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBINU FEES
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
ROUGH PLUMB.,
YARD SPKLR SYSTEM
2ND FL. SO. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SO. FT.
GAS (FINAL)
TEMP. POLE
WALL SO. FT.
DRINKING FOUNTAIN.
SO. FT. ®
WATER HEATER
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
GRADING
cu. yd.
$ plus x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
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.
SO. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/a 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
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 APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
NAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING '
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIONATURESlINITIALS
GARDEN WALL FINAL