05350 (BLCK)4
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 53-600 Vl=, LA QUINTA, CALIFORNIA 92253
Owner '
CE)ACRE11-1 A QCULLEY LOW
Mailing
Address 247 E. TAFQUITZ WAY #2
City Zip Tel.
FALX SPRMGS 92262 322-»i020
Contractor
SAME
Zip Tela
State Lic. I City
& Classif. 3€37934 Lic. # 895
Arch., Engr., "
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) of Division 3 of the Business and -Professions Code, and my license is in full force and
effect
_SIGNATURE `- :r - ' e'' DATE
OWNEWBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,8rsiress and Professions Code: Any city or county which requires a
permit to construct, after, improve, demolish, or repair any structure, prior to its issuance also
requires time applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractors 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 civilpenalty of not more than five hundred dollars ($500).
❑ 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 Contractors 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 6rprovements are not intended or offered for sale. If, however, the building
or improvement is sold wdhim 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 (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who buihls or improves thereon, and who contracts for
such projects with a confractom(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & P.C. for this reason
Date 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(Se ! 800, Labor Code.)
Policy No company LleZZ
❑.Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be corrpleted.ff 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: ft, after making this Certificate of Exemption you should become
subject to the workers' Compensation provisions of the tabor Code, you must forthwith
comply with such provkioris or lids 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 1 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. 05350
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number 774-134-005
Legal Description lot 20 61k 211 t3nit 23
Project Description PF.TATNIMr. 140J.
BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Sq. Ft.
Size
No.
Stories -
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
INSPECTOR
Issued by:
Date 2/14189 Permit
Validated by:
Validation:
Estimated Valuation
2,250
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
54.00
Mech.
Electrical
Plumbing
S.M.I.
- 21
Grading
Driveway Enc.
Infrastructure
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 2/14189 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES ,
IST FL. SO. FT. ® $
UNITS
SLAB GRADE
2ND FL SQ. FT.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEQUIP.
DRAINAGE PIPING
CAR P. SQ. FT.
TEMP. POLE
WALL SQ. FT. ®
GROUT
DRINKING FOUNTAIN
SOFT ®
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 1% c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ic
HOUSE SEWER
INSULATION (SOUND
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 S140WT
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL g
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
v /
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION (SOUND
FINISH GRADING
FINAL INSPECTION 3b
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL 7d