05626 (RC)Building
Address 78-150 TA"ICQ
La menta Nedical
Mailing
Address 521 24th St.
Myta Monica Zip90402
Contractor UAL
Address .
P.O. Box 1000
City Zip92253 Tela
P.O. BOX 1504 No. 05626
78-105 CALLE ESTADO.
LA QUINTA, CALIFORNIA 92253
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City(Zip I
State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Sectionde
7000) of Division 3 ofithe Business and and s Co, and my license is in full force and
"ir
effect.
SIGNATURE--�+!`' �: �',Y /T_� 5;��-'""-- ' DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Busf7ess and Professions Lode: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the appfioant for such permit to file a signed statement that he is licensed pursuant to
the provisions o/ Ne Contractor's License Law, Chapter 9 (commencing with Section 7000) o/
Division 3 o/ 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
subjectstheapplicant to a civil 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, Buisness 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. H, however, the building
orlnprovement is sold within one year of completion, the owner -builder will have the burden
o/ 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 /or
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
,>r
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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. mpany
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the permit is for one hundred dollars (E 100) valuation
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
aliforniaDateowner
NOTICE TO APPLICANT: lf, 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 pemn# 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, Chd Code.)
Lenders 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.
1 certity 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
BUILDING: TYPE CONST. - VE OCC:.GRP. X32
A.P: Number 769-030-035
Legal Description
Project Description Tenant IIIb royek t' for let door
Sq. Ft. No. No. Dw.
Size Stories Units .
New ❑ Add ❑ Alter O Repair ❑ Demolitior ❑
Estimated Valuation $10,000.00
PERMIT
AMOUNT
Plan Chk. Dep.
Distances:
Plan Chk. Bal.
50.00 ,
Const.
Rear Setback from Rear Prop. Line
Mech.
Side Street Setback from Center Line
Electrical
Side Setback from Property Line
Plumbing
FINAL DATE
S.M.I.
Grading
Issued by-
Driveway Enc.
Validated by:
Infrastructure
Validation:
TOTAL
REMARKS
. r�r.�t r�'z .-t : � . � :,:c •y_ fa,'a�tl.. rl(.i n n 4 r,
�': r>" ••. � `f'.iy:tcid�4" 1t:' `1 .fit :1"L." ti— - � - J:.f r �' � ` ,
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
4/10/89
Issued by-
Date 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
FOR. SQ, FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SQ. FT. ®
FINAL INSP.
WALL SQ. FT.
WATER SYSTEM
DRINKING FOUNTAIN.
GRADING
cu. yd.
$ plus x$
_$
URINAL
SQ. FT.
FINAL INSP.
FRAMING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
I
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOODSIGN
VENTILATION
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FIRE ZONE ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIREPLACE
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.
SQ. FT. ®c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
SO.FT.GAR ® VAc
HOUSE SEWER
FINAL INSPECTION
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 SIGNATURES/INITIALS
'
GARDEN WALL FINAL
1