04286 (MFD5)P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 78-033 Cobalt Drive LA QUINTA, CALIFORNIA 92253
vWI MI
Boulevard Development
Mailin
Address 777 S. Main St. Suite £! . _ . ..
CityZip Tel.
Orange 92606 714-411&7-805.6
Contractor
Sam
Address
Zip
State Lic. 462824(City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State I
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, after, improve, demolish, or repair any structure, prior to its issuance also
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) or
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
t 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 (5500)•
❑ 1, 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.)
❑ 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
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.a3800, Labor Code.)
Policy No. Company
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
w WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S100) 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
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 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.
Signature of applicant Date
Mailing Address
City, State, Zip
,94286
JILDING: TYPE CONST. OCC. GRP.
P. Number 613-'790-008
Legal Description
Project Description Plan 3# Ruilding 19
Sq. Ft. 763 No. "^ No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation $561856
PERMIT
AMOUNT
Plan Chk. Dep>
Plan Chk.`Bal.
! if: .
Const.
JQ4 . UU
Mech.
, ' out) �
Electrical
a "�� '41.7t$
Plumbing
63.1)0
S.M.I.w
7
Grading
Driveway Enc.
Infrastructure
FrinaO koect LT zatd
J0 It%
TOTALV$,?•p1
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 7/7/08Permit
Validated by:
Validation:
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
JRICAL FEES
' NO. r PLUMBING FEES
UNDERGROUND
A.C. UNIT
COLL. AREA . .
YARD SPKLR SYSTEM '
C,
BAR SINK
HEATING (ROUGH)
ROOF DRAINS
FORMS
DRAINAGE PIPING �.5`•'
'
DRINKING FOUNTAIN '
ROCK STORAGE - ^' •�,
URINAL
:,oWs(ROUGrH)
WATER PIPING I
HEATING (FINAL)
FLOOR DRAIN
REINF. STEEL
WATER SOFTENER
TEMP. POLE
WASH ER(AUTO)(DISH)
GARBAGE DISPOSAL
WATER HEATER
LAUNDRYTRAY
FINAL INSP.
KITCHEN SINK
T SVC
WATER CLOSET �t
LAVATORY
:NT
SHOWER
- FRAMING �� O FINAL INSP:
BATH TUB
^
,
r
WATER HEATER
w c
SEWAGE DISPOSAL
3i c
HOUSE SEWER y
GAS PIPING
PERMIT FEE
EE ELECT. FEE
SMI FEE PLUMB FEE
HEATING 8 AIR COND. SOLAR r ' s,
"SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA . .
SLAB'GRADE� (' �(
OUGH PLUMB
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
i
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT, WORK
ROCK STORAGE - ^' •�,
r FOUND: REIN
:y V
:,oWs(ROUGrH)
METER LOOP
HEATING (FINAL)
•OTHER APPIEOUIP.`M1
REINF. STEEL
GAS (FINAL)
TEMP. POLE
• GROUT
WATER HEATER
SERVICE
FINAL INSP.
'
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus - X$
=$
LUMBER GR. . t FINAL INSP. �� 2t�'�N
- FRAMING �� O FINAL INSP:
ROOFING
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR -
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
r c_
FINISH GRADING
FINAL INSPECTION V2
CERT? OCC.
ccnirc,ciuei
^
,
r
•
REMARKS:
•4
,,
SIGNATURESIINITIALS
GARDEN WALL FINAL