04205 (MFD5)T -t�t A 4
'�F" �� 04205
P.O. BOX 1504
Building78-105 CALLE ESTADO
Address 70-101 Cobalt -,Drive LA QUINTA, CALIFORNIA 92253 '
Owner
Boulevard Drive BUILDING: TYPE CONST. OCC. GRP.
Mailing
Address 779 S. Main St., ftitO 2:06 A.P. Number 613-790-006
-City Zip Tel. ..,
Orange 92686 714M547-8056 Legal Description L -
Contractor Project Description Yt�;(.�t> near 3.15 0.
Same
Aaaress
City Zip Tel.
State Lic. 4s�84 (City
& Classif. Lic. If
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
f Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed undir provisions of Chapter 9 (commencing with Section
7000) of Divislon.3 of the Business and Professions Code, and my license is in full force and
effect.:.�rr+;}`•:.,lydit
_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) 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 (E500).
O, 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.)
❑ 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 contractors) 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. 3800, Labor Code.)
Y
Policy No. Company L"-'✓' ✓-
0 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars f$100) valuation
or less.)
1 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, alter 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 fending 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.
1 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
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street, Setback.from Center.Line
zrr"�-r'�i^}• ;H*�'t-�-.�t,�.•'!'3�� cr-4��'7� 7! F.t,
Side Setback from Property Line
FINAL DATE16N/S2811 888
Issued by: Date Permit
Validated by:
Validation:
1
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
Sq. Ft, 912
Size
No.
Stories "'
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
$65t225
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
2,15 .61
Const.
331 * ()0 _.
Mech.
36.00
Electrical
44.76 _
Plumbing
75.00
S.M.I.
4.59
Grading
Driveway Enc.
Infrastructure
I., 467.57
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street, Setback.from Center.Line
zrr"�-r'�i^}• ;H*�'t-�-.�t,�.•'!'3�� cr-4��'7� 7! F.t,
Side Setback from Property Line
FINAL DATE16N/S2811 888
Issued by: Date Permit
Validated by:
Validation:
1
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL SO FT (p $+. ..
UNITS' .. ,
COLL. AREA
SLAB GRADE `7 / / �y
ROUGH PLUMB
YARD SPKLR SYSTEM
2ND FL SO FT. a
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR SO FT. at
DUCT WORK
ROCK STORAGE
GAR SO. FT. it
POWER OUTLET _
ROOF DRAINS
METER LOOP
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SO FT. 0
GAS (FINAL)
WALL SO. FT. a
'
DRINKING FOUNTAIN
GROUT
WATER HEATER
URINAL
SO. FT. fa
FINAL INSP.
ESTIMATED CONSTRUCTION VALUATION S
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
GRADING
cu. yd.
$ plus x$
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOI(DISHI
APPLIANCE DRYER
/
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
REMARKS:
LAUNDRY TRAY
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.
- 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/.c
MOUSE 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 GOND. SOLAR
SETBACK
ROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE `7 / / �y
ROUGH PLUMB
- BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF./
AS (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.
Of sc
FINAL INSP.
FRAMING- �Q �"..��
�INAL INSP.
ROOFING
/
I u
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR,
GAR. FIREWALL
LATHING A w— /tit
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCG.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
-