10526 (RR)P.O. BOX 1504 10526.
10526
Building 78-105 CALLE ESTADO
Address 52-795 Villa LA QUINTA, CALIFORNIA 92253 Owner 3,2
Harr Ann Heinae BUILDING: TYPE CONST. OCC: GRP.
Mailing
Address Sc Tae.
A.P. Number
City Zip Tel.
La Quint a 92253 Legal Description
Contractor Project Description
The Nelson Rocifing Co.
Address REROOF
P o. Box 584
City Zip Tel.:
. _ 92261 714./845r-2048
State Lic. City
& Classif. 516729 C39 Lic. # 1654 Sq. Ft. No. No. Dw.
Arch., Engr.,. Size Stories Units
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
City
Zip
State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I herebyy,affirm that I am licensed under provisions of Chapter (commencing with`Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect:?
r
S GNATDATE
OWNER -BUILDER DECLARATION
1 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 e applicant for such permit to file a signed statement that he 'Is licensed pursuant to
the
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 o/ Section 7031.5 by 'any applicant for a permit
Estimated Valuation
3.��Q
- - AMOUNT
PERMIT
Plan CFik.•.Dep.
subjects the applicant to a civil penalty o/ not more than five hundred dollars ($500).
O I, as owner of the property, or,my employees with wages as their sole compensation, will
Plan Chk. Bal.
Const. 30.00
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Bulsness and
Professions Code: The Contractor's License Law does not apply to an owner o/ 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
Mech. '
Electrical
or improvement is sold within one year. o/ completion,- the owner -builder will have the burden
of proving that he did not build or improve for the purpose o/ sale.)
Plumbing
❑ 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 or properly -who builds or improves..thereon, .and who contracts /or
-
S.M.I.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) -
O I am exempt under Sec. B. t: P.C. for this reason
Grading
Driveway Enc.
Date Owner
Infrastructure
WORKERS' COMPENSATION DECLARATION
I
Iehereby 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.) _
Polio No. .Company '
O=Copy is filed with the city. O Certified copy is hereby furnished.
TOTAL
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 anyperson 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 o1 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
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 r
Validated by:
Validation:
V
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
2ND FL. SO. FT.
POR. SQ. FT. ®
GAR. SQ. FT. ®
CAR P. SO. FT.
WALL SQ. FT.
SQ. FT. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER (
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
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.
SQ. FT. ® c
BATH TUB
BOND BEAM
SQ. FT. ®c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
LUMBER GR.
SQ.FT.GAR ® 3bc
HOUSE SEWER
FRAMING
FINAL INSP.
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
L)%
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION•
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL