05099 (SFD)P.O. BOX 1504 No. 05099
Building 78-105 LA QUINTACCALIFORNIA 92253
Address 54-4€i8 Shoat Creek _
Owner
Address 42-600 Cook Street, Suite 200..
City Zip Tel.
Palm Desert 92280 568--2828
Contractor
Address
City
Zip
State Lic. Citi
& Classif. 283134 Lic. # 328
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 Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
_SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Susiness 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 of 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).
❑ 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 appy to an owner or 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 or completion, the owner -builder will have the burden
or proving that he did not build or knprove 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
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
❑ Copy is filed with the city. ❑ 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.)
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
NOTICE TO APPLICANT: ff, after making this Certificate or Exemption you should become
subject to the Workers' Compensation provisions or 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
Lender's Address
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 this application and state that the above information is correct.
1 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. OCC: GRP.
A:P. Number. PGA meat -• Phase 16A
Legal Description
Project* Description Plan im
Sq. Ft. 1334 No.
Size Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Itstlmateo valuation $94,226
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
T $
Mech.
A()
Electrical
Q , 4_4
Plumbing
50
S.M.I.
Grading
Driveway Enc.
Infrastructure
S2.120.49 Q50»25
hC-r"d 4
I nff n �s
TOTAL
REMARKS
bi'rts'I►{iw?s�t�'"'t"t3��1�Y orV
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 1212BPermit
Validated by:
Validation. ��
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
COLL AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL Sp. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. Sp. FT. ®
DUCT WORK
ROCK STORAGE
FOUND. REINF.
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
DRAINAGE PIPING
CARP. SO. FT. ®
WALL Sp. FT.
DRINKING FOUNTAIN.
ICE
FINAL INSP.
URINAL
SO. FT.
WATER SYSTEM
ESTIMATED CONSTRUCTION VALUATION $
GRADING
cu_ yd.
$ plus x$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
ROOFING
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOXDISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
VENTILATION
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING
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/. c
SEWAGE DISPOSAL
S0.FT.GAR ® 3/ec
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.
S (ROUGH) 7
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
ICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu_ yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING S
FINAL INSP.
ROOFING
REMARKS
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR.. FIREWALL
MESH
ULATIONISOUND C
FINISH GRADING
FINAL INSPECTION -
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURE311NITIALS
GARDEN WALL FINAL