04280 (MFD5)• 4 "
P.O. BOX 1504
Building 78-105`CALLE ESTADO
Address 78--105 Cotalt Dative LA QUINTA, CALIFORNIA 92253
vwnci
Boulevard Developmlf Int
Mailing
Address 777 S. -Main St.. St itn 106
City Zip Tel.
Orange 92686 1714-547 8056
Contractor
Ir
Address
City jZip I Tel.
State Lic.5� City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I 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. . X7,'1
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 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 ($500). -
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.)
O 1, 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.)
O 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
Ihereby 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 ' ' I
O Copy is filed with the city. O 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 ($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.
I
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number 613-790-006
Legal Description
Project Description Plan 3 - Buildinq 15
Sq. Ft. 736 No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation $56r886
PERMIT
AMOUNT
Plan Chk. Dep: '
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.)
Plan Chk. Bal.
,
Const.
31.14 • UU
Mech.
J300V
Electrical
41.1 is
Plumbing
bj . uu L
S.M.I.
3 wb
Grading
Issued by:
Driveway Enc.
I agree to comply with all city and county ordinances and state laws relating to building
Infrastructure
1,o-2-7-9 • :1
Fran-ge" 0ev,
-L ZaZ tit. X11
mentioned property for inspection purposes.
Validated by:
Signature of applicant Date
TOTAL
Mailing Address
REMARKS
City, State, Zip
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
ZONE: BY:fT!)'t2hS4i` if`yl > Stt~t efS.Gi 1�•
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Side Street Setback from Center Line
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 Setback from Property Line
Lender's Name
Lender's Address
FINAL DATE
INN i ECT
SPECTOR
This is a building when filled out, signed and validated, and is subject to
permit properly
expiration it work thereunder is suspended for 180 days.
O+
/
I certify that I have read this application and state that the above information Is correct.
Issued by:
Date Permit
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.
Validated by:
Signature of applicant Date
Mailing Address
Validation:
City, State, Zip
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
CONSTRUCTION ESTIMATENO.
ELECTRICAL FEE 53; v
NO. PLUMBING FEES
IST FL SO FT y S
UNITS
COLL. AREA
SLAB GRADE I Qi7
ROUGH PLUMB
Y
ARD SPKLR SYSTEM
2ND FL SO FT. (d
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR SO FT. gr
DUCT WORK
ROCK STORAGE
GAR SO. FT. Gr
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SO FT. C
GAS (FINAL)
TEMP. POLE
WALL SO. FT. rd
DRINKING FOUNTAIN
SO. FT. a
WATER HEATER
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INS:P::.::::::::::d
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
GRADING
-CU. yd.
$ plus x$
WATER SOFTENER.
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
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 @ I v: c
SEWAGE DISPOSAL
SO.FT.GAR @ 3/4c
HOUSE SEWER
GAS PIPING
PERMIT FEE -
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE i'L.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB FEE
STRUCTURE PLUMBING , / ELECTRICAL _ HEATING 8 AIR COND. SOLAR '
SETBACK,y
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE I Qi7
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 INS:P::.::::::::::d
BOND BEAM
WATER SYSTEM
GRADING
-CU. yd.
$ plus x$
_ $
LUMBER' GR. FINAL INSP.
FRAMING ' or O FINAL INSP.
ROOFING
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR -
GAR. FIREWALL
LATHING 61 IrJ (alow
MESH
INSULATION/SOUND
FINISH GRADING
FINAL' INSPECTION
CERT. OCC.
ccurc CIMAl
REMARKS:
-
INSPECTOR'S SIGNATURES11NITIALS
GARDEN WALL FINAL