05040 (SFD)P.O. BOX 1504 N o . b5040
Building 78-105 TCCALIFORNIA 92253
Address 54-839 Shoal Creek LA QUINA
Address 42-600 Cook St., Suite, 200_
CityZip Tel_
Palm Desert 192260 1 568-2828
Contractor
Address ,
State Lic. City ,
& Classif_ % Lic_ # .340
Arch.; Engr.,
Designer
Address I Tel.
City(Zip I
State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 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 Contractors License Law for the following
reason: (Sac. 7031.5,8usiness 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 civilpenalty 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 apply to an owner of property who
builds or inproves thereon and who does such work himself or through his own employees,
Provided that such orrprovements are notintended or offered for sale. If, however, the building
or Improvement s sold within one year of completion, the owner-buffder will have the burden
of proving that he did not build or Improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to corn
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 neednot be completed if the permit is for one hundred dollars (5100) 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 of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply wmM 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 if work thereunder is suspended for 180 days.
I certify that I have read this applicationand 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 We.i t — Passe 19A
Legal Description
Project Description Plan 4GR �
Sq. Ft.� y : P No..�_
Size Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
IEstimated Valuation $122,816
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
P
TOTAL
AMOUNT
4 AA7 _
71
%I
-
/�tp
psi /n
of f�[
•� i M
gA
AA
8
f71.5
-9 •
2R
1.494..18
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
12/23188
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
'1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
'ROuz PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT. ®
FORMS
O EPTI AN
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CARP. SQ. FT. ®
FINAL INSP.
BOND BEAM
WATER SYSTEM
DRINKING FOUNTAIN
WALL SQ. FT. ®
=$
LUMBER GR.
FINAL INSP.
RAMING1
l�
URINAL
SO. FT. @
ESTIMATED CONSTRUCTION VALUATION $
REMARKS:
WATER PIPING
NOTE: Not to be used as property tax valuation
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
SPARK ARRESTOR
LAUNDRY TRAY
AIR HANDLING UNIT CFM
GAR. FIREWALL
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
FINISH GRADING
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ic
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
'ROuz PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
O EPTI AN
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
20 S (FINAL)
TEMP. POLE
GROUT
WATER HEA R
ERVICE (
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
RAMING1
l�
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
HIN
MESH
ULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL