15767 (PLBG)Aivilding 53--475 Vali ijo
'iidress
.,..— loan Bevis
Mailing
Address
City Zip
La Quints 192253
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S tet fen P1ximbin
Address
City
State Lic.
`• &. Classif. .
Designer
Address
City
I Lk
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P.O. BOX 1504
78-495 CALL"E TAMPICO
LA QUINTA, CALIFORNIA 92253
6Z# C -I1
Tel.
Zip (State
Lic. #
CONTRACTOR'S DECLARATION
under provisions of Chapter 9 (commencing -with Section
and Professions Code, and my license is in full force and
I f OWNER -BUILDER DECLARATION
I 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, 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 civilpenally of not more than rive hundred dollars (8500).
❑ 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 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.)
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 propertywhobuilds. or improves thereon, and who contracts for
such projects with a contractor(s) #tensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. t+ 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 A - /
❑ Copy is filed with the city. ECertified copy is he°rebyjfurrilshed.
- wv�nnens�wMre� wuVn t �wnct .
his section need 'no( be cotegJ/ the permit is fo�ron hundred dollars ($100) valuation
or less.)'
I certify thatAn the perfor(nance of th #work for Iwhi?h this permit is issued, I shall not
.employ any prison in any manner so as to become object to the Workers' Compensation
+Laws of California. Vh. Via! •'��^
`•
,k Date j Owner
NOTICE•rTO APPLICANT: Hr/after making this Certftrcate o/ Exemption you should become
subject to the Workers' Compensation provisions o/ the labor Code, you -must forthwith
comply with such provisions or this permit shall be deemed revoked.
WARNING: FAILURE TO SECURE.WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES. -
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 informationis 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.
Signature of applicant Date
No. 15767
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
,Legal Description
Project Description
Septic
Abt><n . Sewer Hookup
Front Setback from Cent ie
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ . Repair ❑ Demolition ❑
Side. Setback fro ropef e
FINAL DATE
ECTO`
Issued by:
Date Permit
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
4
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
30.00
REMARKS'
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Cent ie
Rear Setback from Re : Line
Side Street Setbac Cent
C
Side. Setback fro ropef e
FINAL DATE
ECTO`
Issued by:
Date Permit
Validated by:
Mailing Address vanoaxlon:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEElft
1ST FL. SQ. FT. ® $
UNITS
t� L
SLAB GRADE
ROUGH PLUMB.
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK 1
POR. SO. FT. ®
DUCT WORK
l
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
DRAINAGE PIPING
CARP. SQ. FT. ®
GAS (FINAL)
TEMP. POLE
WALL SQ. FT.
DRINKING FOUNTAIN
GROUT
WATER HEATER
URINAL
SO. FT. ®
FINAL INSP.
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
GRADING
cu. yd.
plus x$
FLOOR DRAIN
MECHANICAL FEES
r v
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
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GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
VENTILATION
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.
SO. FT. RESID ® 11A c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
INSULATIONISOUND
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE LPL.CCK.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 R
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
, $
GRADING
cu. yd.
plus x$
_$
LUMBER GR.
r v
FINAL INSP.
FRAMING
FINAL INSP.
ROOFINGAREMARKS:
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VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
06
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION,G•
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
777
Received -From:
Address:%.Lot(s)
Account No. J� r
Service Address
❑ Meter(s)
❑ Service(s)
1J f ❑ Backtlow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
Sanitation Capacity Charge .
❑ W.S.B.F.C.
❑ Temporary Construction Meter
• Tum bnGhe�" �;; .. _ '.:i,'v�
❑ Uncollected Account -Name
❑ Inspection Fee -Tract -
Fee -
C3 Plan Check Fees Water 1 Sewer,..,,
Tract-
0
ract-❑ Bond Payment - A.D. -
Bond___�
Assmt.
(j Customer Deposit
❑ Other
Remarks:
Tract
G.A. Code
TOTAL $ '
3