003303 (PAT)40
44
P.O. BOX 1504 No
Buildin78-105 CALLE ESTDO .003303
g 79" 260 9. S 6 � LA QUINTA CAL FORNAA 92253
Address
F MC= PZA
Mailing
Address P-0- BOX 2257
CityZip T�745-1521:'-
P MIRSERT...92261 .
Contractor
.. Address.. .
BUILDING:. TYPE CONST. OCC: GRP:.`
A.P. Number
Legal Description
Project Description PAT10. 4 W
City ... - _.... ....
Zip. , -
Tel.' ..
State Lic.
City
& Classif.
Lic. #
Sq. Ft.,
No. No. Dw.
Size
Stories - Units
Arch., Engr.,
Designer.
New O Add ❑
• Alter ❑ Repair ❑ Demolition ❑
Address
Tel.
City
Zip
State
_ .
Lic. #
LICENSED CONTRACTOR'S DECLARATION
hereby affirm that,l am licensedunder provisions of Chapter 9 (commencing' with'Section
7000) of Division 3 of the Business,
usiness and Professions Code, and my license is in full-force'and
effect..
...
... .. .. _ .. ..
SIGNATURE DATE
OWNER -BUILDER DECLARATION
hereby affirm that I am* exempt from the Contractor's License 'Law for.the following
reason: (Sec.. 7031:5,Business and Professions Code: Any city' or county ,which requires a
Permit to construct, alter, improve, demolish, or, iepair •any structure, prior. to its issuance also
requires the applicant /or such permit to file a -signed statement thathe is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section7000)o/
Division 3 ot'the Business 'and Professions Code, or that. he is exeimpt'therefrom, and the basis
for the alleged exemption. Any violation o/ Section 7031:5 by. 'any applicant for a permit
' subjects the applicant to -a civii•penalty o/ not'more'than.five hundred dollars{$500):.
❑ I; as owner of the property, or my employees with wages as their sole: compensation, will
Estimated Valuation
7 e� rJg�
R 5V was
- '- PERMIT'
-
_
..
• •'- AMOUNT -'
- -
Plan. Chk..Dep.
Plan'Chk. Bal. -
Const.
2>. . ft
do the work, and the structure is not intended or offered for sale. (Sec. 7044,• Bulsness-ancF
Professions Code: The -Contractor's License Law_does not applyto an owner of property. who
�.MeCh•.
-
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 ..
or improvement is sold within one year o/ completion, the owner -builder will have the burden
- of proving that he did not build or,lmprove for the purpose o/ sale.). ..
Electrical
- -
Plumbing'
O I, 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
S.M.I. •
_.
- ,.
•• such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ I aim exempt under Sec. B. & P.C. for this reason
Grading
Driveway Enc.
.. ,
' _Date Owner "-�.= "� -.
r -
Infrastructure
- -
WORKERS' COMPENSATION DECLARATION
' I hereby affirm that'] have'a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. ySec. 3800, Labor.Code.)
Policy No. Company
❑ Copy is filed with the city.. ❑ Certified copy is hereby: furnished.
TOTAL
20..00
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION. INSURANCE
REMARKS <..
-
(This section need not be completed if the permit is /or 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.
-{*,'"•{j'Y;g''
�. '+T� ?, s'�}`�''t'
Date Owner
NOTICE TO APPLICANT. It, after making this Certificate of Exemption you should become
' 'subject 'to the Workers" Compensation provisions' of. the Labor Code, you must' forthwith
comply with such provisions or this permit shall be deemed revoked.' -
ZONE: BY.
-Minimum Setback Distances: - -
Front .Setback'from. Center Line
Rear Setback from Rear Prop.. Line
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.)
Side Street Setback from Center Line
Side Setback from Property Line..
Lender's Name
. FINAL DATE
c.
-`Issued by:
Validated by:
INSPECTOR •
Date- AIAIA i Permit
T -
"
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 application and state that the above information'is correct.
]'agree to comply with all'city and counly.ordinarices 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
Validation:
City, State, Zip
HARD COPY
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® $
2ND FL. SQ. FT.
POR. SQ. FT. ®
GAR. SQ. FT. ®
CARP. SQ. FT.
WALL SQ. FT.
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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. p c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
I
,J
v
yA
C
SQ.FT.GAR ® 3/ac
HOUSE SEWER
REMARKS:
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)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
CU. yd.
$ -plus-x$_=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
I
,J
v
yA
C
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND'
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL