10291 (ELEC)4
P.O. BOX 1504
Building 53-999 JE�'AEIdS42d 78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
LANDMARK LAUD
-Mailing : `f
Address 74180 TAMPICO
City
Zip
Tel
LA QUINTA
92253
New ❑ Add ❑
Contractor
SYSTEM ELECTRIC
Address
1278 MONTALMO WAY
City
Zip
Tel.:
PALM SPRINGS
92262
327-7847 .
State Lic.
City
& Classif. 20319
Lic. # 776
Arch:, Engr.,
Designer.
Address
Tel.
City ( Zip( State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION '
I hereby affirm that I am licensed under provisions of Chapter -9 (commencing with Section
70 OO) of Division 3 of the Business and Professions Code, and my license is in full force and
effect
.
{f/:7 ✓t"e,% J.u'- .f"./:�7al..:s�f2�i 'a",% s p % r• f f �r�� .
SIGNATUREi DATE
OWNER -BUILDER DEC411RATION
I hereby affirm that I am exempt from the Cont'ractor'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 703 1. 5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not mote than five hundred dollars.($500). -
❑ 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 improvementis 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 Compensation1nsurance, ora certified copy thereof: (Sec. 3800; labor Code.)
Policy No. .Company '
0 Co
py is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
o WORKERS' COMPENSATION INSURANCE
(This section need not be completed i1 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
employ any peon in any manner so as to become subject to the Workers'. Compensation
Laws of Californirs
a.
Date Owner
NOTICE TO APPLICANT: If, alter making this Certifcate 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
Ihereby 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
No. 10291.
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
Legal Description
Project Description TEMP 901WER POLE
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair. ❑ -Demolition ❑
Estimated Valuation
#200 .
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL"
*3U.00
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
F
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST Fl<. SO. FT. ® $
2ND FL. SO. FT.
POR. SO. FT. ®
GAR. SO, FT. ®
CARP. SO. FT.
WALL SO. FT. ®
SO FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
I 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.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEOUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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 ® V4c
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
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