09243 (PLBG)P.O. BOX 1504 N 0. 09243
78-105 CALLE ESTADO .
Address 53--601 Villa LA QUINTA, CALIFORNIA 92253 '�
Owner
i
BUILDING: TYPE CONST.' OCC: GRP. -
Mailing
Address VS A A.P. Number
City Zip Tel.
. T.R, Z Legal Description
Contractor Project Description
.,n4% �f n
Address B-cak Up
City Zip Tel.
Lmt Qgd-P.9 90620 2131931-7279
State Lic. City
& Classif. Lic. # 1852 Sq. Ft:- No. No. Dw.
Size Stories Units
Arch., Engr.;
Designer New ❑ Add ❑ Alter ❑ Repair ❑ -Demolition. ❑,
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm tf�l�t I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Divisi n'Jrof the Business and Professions Code, and my license is in full for and.
effect.-Al-Ir
ffect�%r.'�Ci'C• l--r-.Its r^
_SIGNATURE Z ,/DATE
OWNER -BUILDER DECLARATION Estimated Valuation
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
".i. requires the applicant /or such permit to file a signed statement that he is licensed pursuant to PERMIT - AMOUNT-
-the provisions -of the Contractor's License Law, Chapter 9 (commencing with Section 7000) o/
'Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
I �Joi' the 'alleged exemption. Any .violation o/ Section 7031.5 by 'any applicant for a permit Plan Chk. Dep.
'subjects the applicant to a civil penalty of not more than five hundred dollars ($500). Plan Chk• Bal.
"0 I, is owner of the property; or my employees with wages as their sole compensation, will
` do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const.
.Code: The Contractor's License Law does not apply to an owner o/ property who
builds or -improves thereon and who does such work himself or through his own employees, Mech_'
provided that such improvements are `not,intended or offered /or sale. If, however, the building
or improvement is sold within bne year.o/ completion, the owner -builder will have the, burden Electrical
o/ proving that he did not build or impiov'e'for the purpose o/ sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing - - 30.00
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for S.M.I.
'such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) -
Grading
❑ 1 am exempt under Sec. B. & P.C. for this reason
Driveway Enc.
Date Owner Infrastructure
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation In urance, or a certified co thereof. Sec. 3800, Labor Code.)
Pot
-4 �T®EiiID
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
• TOTAL 30.00
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS' COMPENSATION INSURANCE
r:
(This section need not be completed i/ the permit Is /or one hundred dollars ($f00J valuation _ r.�r-,a'. .et•. ,-2�+1%oaa,. :on-..ty.c- •.,:.- :a.A
or less.) .. R'G1 •it.r' WV k i-!I'4•9n4_ •`-W ' .. OU s "s.
I certify that in the performance of thg 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 o/ 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
Ihereby 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 it 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
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
2ND FL. SO. FT.
POR. SQ. FT. ®
GAR. SQ. FT. ®
CAR P. SQ. FT.
WALL SO. FT. ®
SQ FT @
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN,
URINAL
WAIER PIPING
NOTE: Not to be used as property tax valuation
ROUGH PLUMB.
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
GAS (ROUGH)
LAUNDRY TRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
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
BOND BEAM
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 C
SEWAGE DISPOSAL
LUMBER GR.
SQ.FT.GAR ® 3/<c
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 APP./EQUIP.
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
�
(
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL