05446 (BLCK)P.O. BOX 1504 N o .
Building 78-105 CALLE ESTADO
Address 46405 Washington SL. LA QUINTA, CALIFORNIA 92253
Owner w
Mailing
Address -
City Zip Tel.
La QuInta 92253 319)56:-290_.
Contractor
Oimer/Euilder -.7-
A
city
State Lic.I City
& Classif. Lic. #
Designer
Address
City (Zip( State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Diviston 3 of the Business and Professions Code, and my license is in full force and
effect
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5.0miness and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repay any structure, prior to its issuance also
requires the app5cant for such permit to lie a signed statement that he is licensed pursuant to
the provisions of the Contractors License Law, Chapter 9 (commenctng with Section 7000) of .
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the affeged exerrption- Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a crWpe n.THy 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 aid who does such work himself or through his own employees,
provided that such irprovanerrls are not untended or offered for sale. If, however, the building
orimprovement is sold wilt. 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 (Sea 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 Sea w, g 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
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No Company
❑ Copy is filed with the city. ❑.Certified copy is hereby fumished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This secdw need not be completed if the permit is for one hundred dollars ($100) valuation
or less.) '
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 r
NOTICE TO APPLICANT. f, after making this Certificate of Exemption you should become
subject to the Workers' Ci pasalkn provisions of the Labor Code, you must forthwith
comply with such pvorsiors 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 property filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certity that 1 have need 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
BUILDING: TYPE CONST. A OCC: GRP.
A.P. Number 617-052--021
0546
Legal Description
Project Description' '44
Of feed
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑ Repair ❑ :Demolition ❑
Estimated Valuation
$11100.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
45.00
Mech.
Electrical
Plumbing
S.M.I.
iv
Grading
Driveway Enc.
Infrastructure
'1[t'i+t�ti.�'.-� `1 :. •�T+t''ii
n j.:5 T rS��S.Z iv� 4 a R A
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 3/6/89 Permit
Validated by:
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
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I SQ. FT.
GROUT
t WATER HEATER
WALL SQ. FT.
FINAL INSP.
DRINKING FOUNTAIN.
SQ FT ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
=$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
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
VENTILATION
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING:
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
LATHING
SO. FT. ®c
WATER HEATER
MAX HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 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
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.
4 EINF. STEEL I?— ` L/
GAS (FINAL)
TEMP. POLE
GROUT
t 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
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
ccurc MUM