9420 (SFD)T a 4bf 4 -4 "
P.O. BOX 1504 No. 9420
Building 7&105 CALLE ESTADO
Address 50-015 Doral Street LA QUINTA, CALIFORNIA 92253
Owner
V3. J. Brock
Mailing BUILDING: TYPE CONST. OCC: GRP.
Address A.P. Number
City Zip Tel.
Legal Description Brock Borates
Crontractor Project Description - Ot 55 2ac�3el 2DR
S
Address
City Zip Tel.:
State Lic. City
& Classif. B 412636 Lic. # 1890 SSq.ize t.22 3 No.
ones No.UniDw.
Arch., Engr.,
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
City Zip State
f: Lic. #
-LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisons'of Chapter 9 (commencing with Section
7000) of Divl/sion 33 O 'the Bu`sinesrs._annd`Prooffessions Code, and my license is in fufvforce/and -
effecty'� s 3./•...1-•�i�-'c...�,--��! ��� .�`_a'/
SIGNATURE G '
.'" -�-<• - s•. l Y/ / DATE
f OWNER -BUILDER DECLARATION.
I hereby afflim 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, atter, Improve, demolish, or repair any structure, prior to Its issuance also
requires the applicant for such permit to the 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).
❑ 1, 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
orimprovement is sold within one year or completion, the owner -builder will have the burden
of proving that he did not build or improve 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 an owner of property who builds or Improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Cont, actor's License Law.)
❑ 1 am exempt under Sec. B. 8 P.C: for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
.1 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
0 -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 ($100) valuation
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor 'Code, you must forthwith .
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is Issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated,'and is subject to
expiration If work thereunder Is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
Estimated Valuation 166, 55$. QQ
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk.. Bal.
624.91
Const.
1j / —.U0
Mech.
71. U U
Electrical
123.85
Plumbing
156.50
S.M.I.
11.6 9
Grading
Driveway Enc.
Infrastructure
3747 .50
M—iii i'L TLIC
14:16.4#
AACZ401 471
4'111 AA -..,LIC -04 114
TOTAL{J
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
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
UNITS
,'/,;�/SETBACK
1/ LAB GRADE !
2ND FL. SO. FT.
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. SO. FT.
,AS (ROUGHo _?� Oj �
`` G
DRAINAGE PIPING
WALL SO. FT.
OTHER APPJEQUIP.
DRINKING FOUNTAIN
SQ FT ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
of6AL INSP. 6 `�
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
HOUSE SEWER
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
RbOUND PLUMBI - `
UNDERGROUND
A.C. UNIT
COLL. AREA
,'/,;�/SETBACK
1/ LAB GRADE !
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
ER OR SEPTI Uv -O
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF. �]�/
v�
,AS (ROUGHo _?� Oj �
`` G
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.
of6AL INSP. 6 `�
MING F! I
FINAL INSP.
jgt4oFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
60± THING
MESH
SULATION/SOUND YL 1
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL