05395 (RPL)3 P.O. BOX 1504
Building 1.)P.�` t - t3 ! ' ' ' 78-105 CALLE ESTADO
Address --i-=> .J r4 4.. a.2 s s' 'fir LA OUINTA, CALIFORNIA 92253
Owner j
Mailing -
Address -77a `J e=t: ,i A ; 3
City Zip Tel.
City Zip Tela
e l
State Lic. City
& Classif. Lic. #
Arch.; Engr.,
Designer
Address Tel.
City I
Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I heretigI irm that I am licensed under provisions of Chapter 9 (commencing with Section
700 Of,pi�visi,ion 33 oY the_Biisiness and,Ptofessions.Code„and my license is in full force and
SIGNATURE...='J�+-.�' -- - DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Bruiress and PnAessars Code: Any city or county which requires a
permit to construct, after, improve, demolish, or repay 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 Contractors License Law, Chapter 9 (commencing with Section 7000) of
ONisfon 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 civif penalty or not more than five hundred dolfars ($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 Contractors License Law does not appy to an owner of property who
builds or improves thereon and who does such ark himself or through his own employees,
Provided that such improvements are not intended or offered for safe. h however, the building
or 6nprovement is sold within one year of completion, the owner -budder will have the burden
of proving that he did not build or improve for the putpose of safe.)
❑ 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 appy to an owner or property who bolds of 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_ R g P -C. for this reason
No. 05395
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number r PIVA t
r
Legal Description
Project Description r -c; 'A- �"` �• /Z ! =r^ A V
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
IEstimatea Valuation ..-7 f 7 V u
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Date owner I Infrastructure
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of_consent to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy thdr f.,(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 riot be completed i1 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
aliforniaDateOwner
NOTICE TO APPLICANT: ff, after malmg this Certificate or Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such Provisions or this pemmt shaft be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, CW Code.)
Lenders Name
Lenders Address
This is a building permit when property filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days- .
I certify that 1 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
ateMailing Address
City, State, Zip
TOTAL
AMOUNT
REMARKS '
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
Issued by: Date t Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
PLUMB.—/
YARD SPKLR SYSTEM
2ND FL. SO. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SD. FT. ®
DUCT WORK
ROCK STORAGE
FOUND. REINF.
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
DRAINAGE PIPING
CAR P. SO. FT. ®
GROUT
WATER HEATER
DRINKING FOUNTAIN,
WALL SO. FT. ®
FINAL INSP.
BOND BEAM
WATER SYSTEM
URINAL
Sp. FT. @
GRADING
,cu. yd.
$ plus x$
=$
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP. 2 2
WATER PIPING
NOTE: Not to be used as property tax valuation
ROOFING
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
SO.FT.GAR ® V4c
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
UMBING
RGROUND,3y-
A.C. UNIT
COLL. AREA
SLAB GRADE
PLUMB.—/
G ✓ ,/ v
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS(ROUGH)5 Z
ETER 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.
FINAL INSP. 2 2
FRAMING
FINAL INSP.
ROOFING
%' .p
%
REMARKS:
VENTILATION
FIRE ZONE ROOFING '
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTIONZ—Z�d D
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
t