9421 (SFD)T a 0
it!t 4 4Qw
Building
Address ss 50-115 Doral Street
Addr
Owner
M. J. Brock
Mailing
Address
City lZip
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
I
SAME
Address
Zip
State Lic. City
& Classif. B 412636 Lic. # 1890
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (cc
7000) of"Division 3ffoofff the Business and Pro�fe6sssiions Code, anrd!my lic
effect. � �' f S P
{--/ OWNER -BUILDER DECLARATION I
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
r 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 of the Business and Processions 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.(E500).
❑ 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 w19 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. .Company
CpGopy 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 (E100) 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., It, alter 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
No. 9421
BUILDING: TYPE CONST. OCC: GRP.
P. Number
Legal Description Brock tiornes
Project Description Lot 57 Model 2AR
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:
Sq. Ft.2283
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ -Demolition ❑
Estimated Valuation
156, 558.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
�� 1
Const.
- U
Mech.
707U -
r •
Electrical
1,4.3. 55
Plumbing
LSb •
S.M.I.
11. b
Grading
Driveway Enc.
Infrastructure
`� / • :)b
Arm In PUMIC
t616.
a A3t�y
V I I I r`tnitlt115 x 4
TOTAL'{
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
1ST FL. SO. FT. ® $
UNITS
A.C. UNIT
2ND FL. SO. FT.
n
�6LABGRADE �-��-
`
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
WER OR Si/ Lfb f
ROUGH WIRING.
DRAINAGE PIPING
CAR P. SO. FT. ®
DUCT WORK
ROCK STORAGE
WALL SO. FT.
AS (ROUGH) d ?.j
[
DRINKING FOUNTAIN.
SO FT ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
REINF. STEEL
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
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
WATER SYSTEM
LAUNDRY TRAY
AIR HANDLING UNIT CFM
$
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 ® 1//a c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
FIREPLACE
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
ROUND PLU No.Ot
UNDERGROUND
A.C. UNIT
COLL. AREA
n
�6LABGRADE �-��-
`
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
WER OR Si/ Lfb f
ROUGH WIRING.
DUCT WORK
ROCK STORAGE
REOUND. REINF.
✓
AS (ROUGH) d ?.j
[
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.
NAL INSV —G - /
^
RXFRAMING - / /_
/�
FINAL INSP.
Fx OFING /
7.3 I
-7REMARKS:
` l
(/G`
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
2bttATHING '7 ' V
MESH
PaNSULATIONISOUND
FINISH GRADING
.FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATUREWINITIALS
GARDEN WALL FINAL