09128 (MISC)Building
Address ... 52-06
Owner'
Mailing
Address P.O. BOX
City .Zip
'ie3` i3Lt2�A��"
Contractor
8n'rsn:arlt�aoi 3r�far
Arldrasc... '.
Zip
P.O. BOX 1504
No. 9$
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253..
BUILDING: TYPE CONST. ., OCC: GRP. '
A.P. Number
Tel.
Legal Description
Project Description CD+gtAS— _CW r44 V.Alr"4m
State Lic. I City
& Classif. Lic. #,
Arch.; Engr.,
Designer
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 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,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its .issuancealso
requires the applicant for such permit to file 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 five hundred dollars ($500t.
ghas owner of the property, or my employees with wages as their sole compensation, will
!,he work; and the structure is not intended or offered for sale. (Sec. .7044, Buisness and
- Pao/essions 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,
provided that' such'. improvements are not intended or .offered .for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder 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 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 to . ' _ ` �..i• �'. �.
f
WORKERS' COMPENSATION DECLARATION...
herebyaffirm 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.
j 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: If, 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.
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
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.
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. _
i Signature of applicant Date'
Mailing Address
City, State, Zip
Sq. Ft. No. No. Dw.
Size . I Stories -. Units
New ❑ Add ❑ Alter ❑ Repair ❑- . Demolition ❑
Estimated Valuation
PERMIT
AMOUNT.
Plan Chk. Dep.
Plan Chk. Bal.
Const.
5 110
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
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
Issued by: Date Permit
Validated by:
Validation:
1
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
2ND FL. SO. FT.
ROUGH PLUMB.
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POR. gq, F7. ®
SEWER OR SEPTIC TANK
ROUGH WIRING
GAR. Sq. FT. ®
POWER OUTLET
ROOF DRAINS
FOUND. REINF.
GAS (ROUGH)
DRAINAGE PIPING
CAR P. SO. FT.
HEATING (FINAL)
OTHER APPJEOUIP.
WALL SO. FT.
GAS (FINAL)
DRINKING FOUNTAIN.
SO FT ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER HEATEF
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
'? MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN .
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FINAL INSP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
/��
v ✓
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 ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
MESH
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 APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATEF
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ -Plus-X$-=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
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v ✓
(_
RRKS:
EM
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL