003197 (PAT)• WW.
44 CJ
P.O. BOX 1504 No. 003197
Building 78-105 CALLE ESTADO
Address 46-460 Jefferson LA QUINTA, CALIFORNIA 92253
Owner .
Mailing BUILDING: TYPE CONST. -- OCC: GRP.
r �" •'
Address Cir A.P: Number 617-160-009City JZip Tel.
,. La Quint 92253 342-0Z� Legal Description
Contractor
.... Project Description &'e1"�Y1d8
Omer/Builder
Address .
-.....Cit . ]Zio y Tela
State Lic. City
& Classif. Lic. # Sq. Ft. No. No. Dw.
-- Arch., Engr., .. _ ..
Size • - Stories Units
Designer New Q Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel. .
City Zip State
Lic. # .
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section ' n
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
_ SIGNATURE DATE
OWNER -BUILDER DECLARATION Estimated Valuation.
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!W 01"
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 PERMIT - -AMOUNT
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 Ialleged exemption. Any violation of Section 7031.5 by 'any applicant for .a permit .Plan Chk. Dep.
'subjects the applicant to a civil penalty of not more than,five hundred dollars ($500). • ' '
❑ I, as owner of the property, or myemployeeswith'wages as their sole compensation, will Plan. Chk. Bal. a�a� M1
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const..
Professions Code: The Contractor's License Law does not. apply :to_an owner of property whoR
builds or improves thereon and who does such work himself -or through his own employees, Mech.
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 Electrical
. 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- Plumbing
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 S.M.I. K�
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) - _.
Grading
❑ I am exempt under Sec. B. 8 P.C. for this reason
Driveway Enc.
Date + " j z"• Owner �.l -*..,!c- .0 Infrastructure
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
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
TOTALAh
CERTIFICATE OF EXEMPTION FROM REMARKS
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, I shall not :.nr. ;c ng a rM c--::. n „ •oar , n -r i nemploy any person in any manner so as to become•subject to the Workers' Compensation
Laws of California. 2 _ 0 f Gtt. ,�}.t�� a
Date owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become ZONE:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances:
BY:
BY:
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
1hereby 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
This is a building permit when properly filled out, signed and validated, and is subject to FINAL DATE INSPECTOR -
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. Issued by: Date'' Permit
1 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
HARD COPY
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® $
2ND FL. SO. FT. ®
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. SO. FT.
WALL SO. FT. @
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM 'p
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APP.IEQUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
REMARKS:
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 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
ROCKSTORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEQUIP.
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
�INAL INSPECTION
CERT. OCC.
FENCE FINAL -
INSPECTOR'S SIGNATURESIINITIALS.
GARDEN WALL FINAL
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