003118 (BLCK)Building
Address .53-154 Avenida Dials
Owner
Address P. 0. Box 174
City lZip
Contractor
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
2260' h 345--
ress .. . . .
City' " Zip Tela
Palm De rt 92260 345-7352
State Lic. City
& Classif. Lic. #
Arch.,-Engr:,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affi m 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 fullforce and'
effect. /fFst�°, .I /.. •'. X,f,i..
SIGNATURE 1.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). '
❑ 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 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 Compensation, Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No.f — Companyy
O Copy Willed 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 ($100) valuation
or less.) -
I certify that in the performance of the 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 or 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 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 thatthe 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
HARD COPY
No. 003118
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number 774-002-003
Legal Description
Project Description 55' of Sttj1'dfsi� wall
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Center Line
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add D
Alter ❑
Repair ❑ Demolition ❑
FINAL DATE
INSPECTOR
Issued by:
DateC./O)i !Aipermit
Validated by:
Validation:
Estimated Valuation
$1 194.00
PERMIT
AMOUNT
Plan Chk. Dep.
-
Plan Chk. Bal.
Const.
C 9 n n a
Mech.
Electrical
Plumbing
S.M.I. --
Grading
Driveway Enc.
Infrastructure
TOTAL
49A MIA
REMARKS
3t) 1..fiJt!'
i l�itf•It. j :tr.s-+
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:
DateC./O)i !Aipermit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
N0. ELECTRICAL FEES
NO. PLUM13ING': FES
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
VeyiOUGH PLUMB BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. @
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
DRAINAGE PIPING
CAR P. I SQ. FT.
GAS (FINAL) TEMP. POLE
WALL SQ. FT.
DRINKING FOUNTAIN ;
SQ. FT. ®
WATER HEATER SERVICE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property lax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
GRADING
cu. yd.
plus x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
VENTILATION
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.
SQ. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MECRO 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
VeyiOUGH PLUMB BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANKe/doDk+61-1 WIRINGG -
_
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH) METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
REINF. STEEL
GAS (FINAL) TEMP. POLE
GROUT
WATER HEATER SERVICE
FINAL INSP.
Q OND BEAM
WATER SYSTEM
$
GRADING
cu. yd.
plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING 6-a
FINAL INSP.
ROOFING
DEC g
/
�v)
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
CERT. OCC.
FENCE FINAL
TOR'S SIGNATURESIINITIALS.
t
GARDEN WALL FINAL