06384 (SFD)4
P.O. BOX 1504
Building S4-455 Shoal Creak LA gUINTAC
Address CALIFORNIA 92253
Owner
Mailing
Address Irm $ry i
City Zip Tel.
. Palm Desert 1 92260 568-2828
Same
Address
State Lic. 288130 Lic.
328
& Classif. Lic. # -
Arch.; Engr.,
Designer
Address 1 Tel.
City IZip 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.A� ,{ }
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,8usiness and Professions Code: Any city or county which requires a
Permit to construct, alter, krprove, denwlsh, or repair any structure, prior to its issuance also
rmit to file a
suant to
the provisioires the ns Net for such
License Law,�Chapterned atement that he is ficensed9 (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 penally of not more than fire 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 properly who
builds or knproves thereon and who does such work himself or through his own employees,
provided that such krhprovements are not intended or offered for sale. If, however, the building
or knprovement is soli within one year of completion, the owner -builder wig have the burden
of proving that he did not did or krhprove for the purpose of sale.)
O 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
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No Comfy -
R O 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 donars (E 100) valuation
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employany person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT, lt, after makng this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provsfons or this permit shall 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, 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 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 authorae representatives .of this city to enter the above.
mentioned property for inspection purposes
Signature of applicant Date
Mailing.Address
City, State, Zip
No.
LDING: TYPE CONST. OCC: GRP
3- �e
08384
Number T -A t42A11tt, TY m*Ah 91A
I Description
:ct Description Tract 20717-3, Pian 4C
Sq. Ft.191$ • w No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
C *tGG; 7A
Const.
755,00
Mech.
51.00
Electrical
112.84
Plumbing
131.00
S.M.I.
7 9.31
Grading
Driveway Enc.
Infrastructure
$2,488.36
1,494.18
Legis Credit
1,.434.18
TOTAL
$3,116.79
REMARKS
�r
S.�tfJ1`tStPF+�1:�1�rr�tiw
y _
il�16.79 w
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
X3128/89
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL SO. FT. ® $
UNITS
GRADE 'J
RSPGH PLUMB.//
BONDING
YARD SPKLR SYSTEM
2ND FL SO. FT.
FORMS
��yy/
ER OR SE IC TA KP r
ROUGH WIRING,
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
(ROUGH) ��
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SO. 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._f,
[�6RAMING ,�
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
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
SQ. FT. ® c
WATER HEATER
MAX HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® IVs c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
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
D PLUMBING /I � %
NDERGROUND
A.C. UNIT
COLL. AREA
GRADE 'J
RSPGH PLUMB.//
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
��yy/
ER OR SE IC TA KP r
ROUGH WIRING,
DUCT WORK
ROCK STORAGE
F UND. REINF.AS
(ROUGH) ��
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
EINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ -Plus-X$-=$
LUMBER GR.
FINAL INSP._f,
[�6RAMING ,�
INAL INSPa-�U
htR00FINGt -&?
REMARKS:
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
THING
MESH
(`II SULATIONISOUNLI � �v
FINISH GRADING
FINAL INSPECTION -
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL