05441 (ELEC)Tibf 4
P.O. BOX 1504 No. 05441
Building {� j f /� 71105 CALLE ESTADO
Address C? �% .5f YQ,4L�f �^� OUINTA, CALIFORNIA 92253
Owner _ _
fwl,i! Al l,S�. OFSf5f''Zt, f N�'"k�5 BUILDING: TYPE CONST. OCC: GRP.
Mailing �
Address Y2 _ 6.9 u 5W TC— ;3 0 0 A.P. Number
City 1441 t. Zip Tel.
V- " -7/6 Legal Description
Contractor ,r;� 1. �, CJ ,e,r h,.
Project Description � rJd�
Z
Address 0A Rf ill
City Zip Tela
State Lic. City
& Classif. 2> rj Lic. # �- -t Sq. Ft. No. No. Dw.
Arch., Engr.,
Size Stories Units
Designer New ❑ Add ❑ Alter ❑ Repair'❑ Demolition ❑
Address Tel.
City Zip +. 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 li)ense is in full force and
effect -
SIGNATURE ',r .� _ r fit' ° DATE
OWNER -BUILDER DECLARATION Estimated Valuation
1 hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031-5,Business and Professions Code: Any city or county which requires a
Permit to construct, atter, 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 PERMIT AMOUNT
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 Plan Chk. Dep.
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 Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const.
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, Mech-
provided that such improvements are not intended or offered for sale. If, however, the building
or Improvement is sok/ within one year of completion, the owner -builder will have the burden Electrical
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 coir Plumbing
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 S.M.I.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading
❑ I am exempt under Sec B. & P.C. for this reason
Driveway Enc.
Date owner f% Infrastructure
WORKERS' COMPENSATION DECLARATION
1 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 Company
❑.Copy is filed with the city. ❑ Certified copy is hereby furnished.
TOTAL= +` N
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS' COMPENSATION INSURANCE
(This section need rat be completed ff the permit is for one hundred dollars ($100) valuation ' 'tt1 x3-Tyt ti`ifYR r V f 33.51110
5T4110
1
or less-) - `
I certify that in the performance of the work for which this permit is issued, I shall not
employ any pperso
ornian in any manner so as to become subject to the Workers' Compensation
Laws of Calif
Date Owner
NOTICE TO APPLICANT: ff, after making this Certificate of Exemption you should become ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit Shah be deemed revoked. Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Cfvfl Code.) Side Setback from Property Line
Lenders Name
Lenders Address FINAL DATE INSPECTOR
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 certify that 1 have read this application and state that the above information is correct. Issued by: Date Permit
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- Validated by:
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
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
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEV. POLE
GROUT
DRAINAGE PIPING
CAR P. SQ. FT. ®
FINAL INSP.
WALL SQ. FT. ®
WATER SYSTEM
DRINKING FOUNTAIN
GRADING
cu. yd.
$ plus x$
_$
URINAL
SO. FT. g
FRAMING
FINAL INSP.
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
REMARKS:
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
LAUNDRYTRAY
AIR HANDLING UNIT CFM
SPARK ARRESTOR
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.
SQ. FT. ® c
BATH TUB
INSULATIONISOUND
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/. c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/.c
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.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEV. POLE
GROUT
WATER HEATER
ERVICE �1
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
I GRADING
Ap-"SPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL