14776 (BLCK)r '
P.O. BOX 1504 I N o . 14776
Building 78-495 CALLE TAMPICO
Address 98-715 La. Palma Drive LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address SaMe .
City Zip Tel.
r a .Qui nta 92253
Contractor
Tom Stone Masonry
Address
P.O. Box 2333
Cita Zip ._. Tel.:
ha Qninta 92253 564--2128
State Lic. City
& Classif. 4942557 Lic. # 1220
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
ffect..,i''jy . .y r
! SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Busfness and Professions Code: Any city or county which requires a
permit to construct, atter, 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 or the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation or Section 7031.5 - by 'any applicant for a permit
subjects the applicant to a civrl'penalty of not more than Ove hundred dollars ($500).
❑ 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 orimprove for the purpose or 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) pcensed 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 1 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.)
PNo. Company
MCopy is filed with the city, O Certified copyis 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 the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation '
Laws ofCalifornia
Date ., Owner
NOTICE TO APPLICANT: H, 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. . . .
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 '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
ateMailing Address
City, State, Zip
BUILDING: -TYPE CONST.
A.P. Number
Legal Description
Project Description 140 If of
Sq. Ft. No.
Size Stories
New ❑ Add ❑ Alter ❑
Estimated Valuation
53.500.0
PERMIT
Plan Chk. Dep. '
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
_OCC. GRP.
m' garden wall.
No. Dw.
Units
Repair ❑ Demolition ❑
AMOUNT
63.00
63.00
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: A
Validation: j I�
FEB 2 3 lg�
Rv —
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBIW%! FEES
1ST FL. SQ. FT. ® $
UNITS
2ND FL. SQ. FT.
SLAB GRADE
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. SQ. FT.
DRAINAGE PIPING
WALL SQ. FT. ®
_
DRINKING FOUNTAIN.
SO. FT. ®
GAS (ROUGH)
URINAL
ESTIMATED CONSTRUCTION VALUATION $
HEATING (FINAL)
WATER PIPING
NOTE: Not to be used as property tax valuation
REINF. STEEL
FLOOR DRAIN
MECHANICAL FEES
TEMP. POLE
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY.
AIR HANDLING UNIT CFM
WATER SYSTEM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP US&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. Fr. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® V4c
HOUSE SEWER
FIREPLACE
GAS PIPING
PERMIT FEE
SPARK ARRESTOR
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 HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
`cu. yd.
$ plus
x$ _$
LUMBER GR.
-
FINAL INSP. _
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH '
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
N
I