15306 (COMB)". P.O. BOX 1504 No. 15306
ilding78-495 CALLE TAMPICO
'Avenida
i A dress 53-58V Diaz LA QUINTA, CALIFORNIA
92253
Owner
Et3.i38
BUILDING: TYPE CONST. OCC: GRP.
.,,•
Wlailing
Address saMe any Above
A.P. Number
City
Zip
Tel.
. La Quinta
92253
Legal Description-.
Contractor
'd6n-stiuction
PrrSject Description COnV -d t 111in.ina Room to StgOrnnrn.
Dt.
Address
h6ust. -,-Add' 1201f of f;
72-971 36ib Ave.
d City ..�; ,
Zip
Tel.:
.1000 palms
343-2578.
' State Lid'
City
& Classif..
676429
Lic. #
Sq. Ft. No. No. Dw. " K
Size Stories. • Units
Arch:, Engr.,
'Designer
New ❑ Add O • , ' Alter,(] Repair ❑- Demolition's
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
. ?s effect.
,&... SIGNATURE DATE
_
: OWNER -BUILDER DECLARATION
I hereby'affinn.that:I am exempt from the Contractor's License Law. for the following
Estimated VdlUatl, r n
Q2,520,06
' reason: (Sec. 7031:5, Business and Professions Code: Any city or county which requires a
permit 'to construct, utter, 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
_
I . -
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 thaCNe is exempt therefrom, and the basis
-
-
for the alleged 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 (8500).
Plan Chk. 3:) •'0
•: ❑ I, as owner of the property; or my employees with wages as their sole compensation, will -
,Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Con St. . �T
-. Professions Code: The Contractor's License Law does not apply, town owner or ,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
Mech. - -
' or improvement is, sold .within one year of completion, the .owner -builder will have the burden
Electrical. - is.
of proving that he did not, bulk! or improve for the purpose of sale.)_
.-GO
01, 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 to -owner who builds or improves thereon, and who contracts for
�3C
S.M.I.
not apply an of property
'such projects with'a contractors) jiaensed pursuant to the Contractor's License Law.)
6,;i ,
Grading
' ..9d'am exempt under Sec. B. & P.C. for this reason
Driveway Enc.
Date Owner
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
q opyis filed with.t city �O Ce Ified co sY y furnished.
��
TOTAL 11134 3 5`
�IgCATE OF E*E%1'470N FROM
a
.�t;`C
WORKERS' COMPENSATION INSURANCE
REMARKS,
i(This section need•'rot be completed if the permit is for one hundred dollars (8100) valuation
-
' or less.)
i I certify that in the performance of thF 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. tt,, after making this Certificate of Exemptionyou should become'
ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you • must forthwith
comply with such provisions or this permit shall be deemed revoked.
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
Side Street Setback from'Center Line
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,
Side Setback from' Property Line
DAMAGES AS PROVIDED' FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEYS FEES.
This is a building permit when properly filletl out, signed and.validated, and ie subject to '
FINAL DATE INSPECTOR
expiration if work, hereunder is suspended for 180 days. .
I certify that I have'read this application and state that .the above information is correct.
Issued by: Date
ermi
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-.' '.
f
_
mentioned property for Inspection purposes.
Validated by:
Signature of applicant Dale'
o/►T
OCT'
Mailing Address
Validation: I
I City, State, Zip
4
3y
{
CONSTRUCTION ESTIMATE NO. I ELECTRICAL FEES NO. I I PLUMBING FEES '
1ST FL. SQ. FT. ® $
UNITS
UNDERGROUND
A.C. UNIT
COLL. AREA
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
BONDING
HEATING (ROUGH)
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APP./EQUIP.
DRAINAGE PIPING
CAR P. S0. FT.
TEMP. POLE
WALL SO. FT.
GROUT
DRINKING FOUNTAIN
SO. FT. ®
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
=$
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
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
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
GAR. FIREWALL
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® V4c
HOUSE SEWER
INSULATION/SOUND
GAS PIPING
PERMIT FEE
FINISH GRADING
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 APP./EQUIP.
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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
% RECEIPT City of La Quinta, 78-495 Calle Tampico, P.O. Box 1504, La Quinta CA 92253
DATrj�_ � J 19 • — NO: 1089 O G C,
/RECEIVED FROM U 7
ADDRESS G
DOLLARS $
FOR X.
ACCOUNT HOW PAID
AMT. OF C
ACCOUNT
AMT. PAID HECK
BALANCE MON Y
DUE
"•• • 4 •tib_-\ :. •\ \ �_:.\ • 0 '►•i • A\
1. Business Name:
2. Business Address: /,;� 7 7/
3. Mailing Address:
4. Business Phone:
5. Owned By: CORPORATION PARTNERSHIP IVIDU
6. If Corporation or Partnership: TAX I.D.
7. If Individual Owner: Social Security #
8. Name of Owner or Officers and Title:
9. SBEResale Number:
10: Number of Decals Needed:
A. Type of Contractor:
B. Classification:
C. State License Numbe
A or B License Classification $100.00 Per Year ori -Annual
C License Classification $ 50.00 Per Year or mi -Annual
CONTRACTORS ARE ON A CALENDAR YEAR BASIS ONLY; ANNUAL FROM JANUARY 1ST THROUGH
DECEMBER 31ST. SEMI-ANNUAL FROM JANUARY 1ST THROUGH JUNE 30TH; OR JULY IST
THROUGH DECEMBER 31ST.
I HEREBY CERTIFY that all the information supplied by me is 'correct and any
licenses required by the County, State.or Federal Government have been issued
to me d a in full force and effect.
Drt.N // / / 9S
Signature Title C,,Datd