05683 (RC)Building
AAA---- 7$-120 CALLE `1'A ICO
Owner
PRANCES BACK
Mailing
Address SAM,
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
� ! . .
City Zip 7 -Tel.
LA (UMA .92253 619/$§4-4.161
Contractor
R. A. HENRY 00.
Address P,0- BOX .835
City Zip Tel.:
M- XM LA 91740 $14/963-9488
State Lic. City
& Classif. B^-1 345667 Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I 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
SIGNATURE v J1 DATE
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,13usiness 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 permit to rile a signed statement that he is licensed pursuant to
the provisions or the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
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
subjects the applicant to a civil penalty of not more than rive hundred dollars ($500).
❑ 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, Suisness and
Professions Code: The Contractor's License taw 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
orimprovement 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 sale.)
❑ 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 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 Y
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Com `
pen Insurance, or a certified cop hereof: (Sec. 3800, Labor Code.)
Policy No. Company 4,�� Z
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California
Date Owner
NOTICE TO APPLICANT: ft, after making this Certificate o/ Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lenders Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that l have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives .of this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
No. 05683
BUILDING: TYPE CONST. OCC: GRP.-
A.R. Number 769-0-V-016
-016
Legal Description
Project Description
REMARKS ,.. ..,r. = . -
�Y,'r.Fss2!'r$r#T�. 3e�.#sK.tE'rYt::i .t,+:.w 74#'# t . +ti` a
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from.Center Line
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolitionm ❑
FINAL DATE
INSPECTOR
4/28/89Permit
Issued by:
Date -
Validated by:
Validation:
Estimated Valuation
$1019" .00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
117.00
Mech.
Electrical
Plumbing
S.M.I.
.7Q
Grading
Driveway Enc.
Infrastructure
TOTAL
% f
REMARKS ,.. ..,r. = . -
�Y,'r.Fss2!'r$r#T�. 3e�.#sK.tE'rYt::i .t,+:.w 74#'# t . +ti` a
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
INSPECTOR
4/28/89Permit
Issued by:
Date -
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL SO. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SO. FT.
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING.
MOBILEHOME SVC.
BAR SINK
POR. SD. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SO. FT. ®
FINAL INSP.
BOND BEAM
WATER SYSTEM
DRINKING FOUNTAIN.
WALL SQ. FT.
LUMBER GR.
FINAL INSP.
URINAL
Sp. 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
LAUNDRY TRAY
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/. c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ic
HOUSE SEWER
CERT. OCC.
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 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
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESJINITIALS
GARDEN WALL FINAL