14833 (RR)Building
Address 54"'60Avt' • Dia
Owner Tom 81.Iler
Mailing gainip
Address
P.O. BOX 1504
78-495 CALLE TAMPICO
LA OUINTA, CALIFORNIA 92253
City Zip Tel.
La Quinta, CA 32253
Contractor
owndr/Builder
Address
- MD ' - ITel.:
State Lic. I City
& Classif. Lic. #
Arcn.- Lngr., "
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) t. of Division 3 of the Business and Professions Code, and my license is in full force and
effec.
SIGNATURE 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 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 of Section 7031.5 by 'any appllcant for a permit
subjects the applicant to a civil penalty of not more than rive hundred dollars ($500). .
1, as owner of the property, or my employees with wages as their sole compensation, will
Go the work, and the structure is not intended or offered far 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 knprove for the purpose of sale.)
O 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 on, owner of property who builds or improves thereon, and who contracts for
such projects with'a contractors) (lcensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & P.C. for this reason
t
I. Owner ' `^
i
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. 3600, Labor Code.)
Policy No. ,Company
. O Copy is filed 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 if# person in any mannersb` to, become subject to the Workers' Compensation =
�La es<ot. �lrp�nia. d �[ . to•,L-•
Da J Owner i
NOTICE Td ff, 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 8706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
This is a building permit when propeily 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.
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.
Signature of applicant Date
Mailing, Address
City, State, Zip
No. 14833
LDING: TYPE CONST. OCC. GRP,
P. Number
egal Description
roject Description $
ZONE: BY: '' r
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from RAllr�
Side Street Setback
Side Setback from P
FINAL DATE INS
Issued by: Date
W
Validated by -
Validation:
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
$11800.00
PERMIT
AMOUNT
Plan Chk. Dep. .
Plan Chk. Bal.
Cohst.
30.00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
30.00
TOTAL
REMARKS
ZONE: BY: '' r
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from RAllr�
Side Street Setback
Side Setback from P
FINAL DATE INS
Issued by: Date
W
Validated by -
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING; FEES
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT. @
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. I SO. FT. ®
FINAL INSP.
WALL SQ. FT.
WATER SYSTEM
DRINKING FOUNTAIN
GRADING
cu. yd.
$ plus x$
=$
URINAL
SO. FT. ®
FINAL INSP.
FRAMING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE . DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
I
I IKITCHEN 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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1'A c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
FINAL INSPECTION
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 APPJEQUIP.
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
s
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