12625 (INST)• � yY
P.O. BOX 1504 N o . 126.25
Building 51-790 Villa 78105 CALLE ESTADO s
Address LA QUINTA, CALIFORNIA 92253
Owner
Peter G60sseud
Mailing BUILDING: TYPE CONST. OCC: GRP.
Address SaMe A.P. Number
CityZip Tel.
LQ. CA. 922.53 564-2135 Legal Description
Contractor-° Install. '24" -Gas Line.
e'
owner Buildr Project Description
Address
City Zip Tel.
State Lia City
& Classif. Lic. # Sq. Ft. No. No. Dw.
Size Stories Units
Arch., Engr.,
Designer New f Add ❑ Alter ❑ Repair ❑ Demolition ❑
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 DATE a
OWNER -BUILDER DECLARATION Estimated Valuation
I hereby affirm that I am exempt from the Contractor's License Law for the following 200.00
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 AMOUNT
requires the applicant for such permit to file a signed statement that he is licensed pursuant to PERMIT '
the provisions o/ the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 o/ the Business and Professions Code, or that. he is exempt therefrom, and the basis -
•lor 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 live hundred dollars ($500). Plan Chk.. Bal.
❑ 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, Suisness and Const.
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, Mech.
provided that' such Improvements are not intended or offered /or sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden Electrical
of proving that he did not build or improve for the purpose o/ sale.)
0 1, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing ISAO
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner o/ property who builds or improves thereon, and who contracts for S. M. 1.
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 Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS s
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.) I
I certify that in the performance of thg work for which this permit is issued, I shall not 1 t
employ any person in any manner so as to become subject to the Workers' Compensation i
Laws of California. z 1 4 1qq4
Date_NOTICE TO APPLICANT. NT:I/, after making this Certificate of Exemption you should become ZONE: BY:�
1 q
subject to the Workers' Compensation provisions o/ the Labor Code, you must forthwith Minimum Setback Distances: t
comply with such provisions or this permit shall be deemed revoked. f
Front Setback from Cen eW '
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) Side Setback from Property Line
Lender's Name
Lender's I Address
This is a building permit when properly filled out, signed and validated, and is subject to FINAL DATE INSPECTOR
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. Issued by: Date Permit
1 agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives sof this city to enter the above-.
mentioned property for inspection purposes. Validated by:
Signature of applicant Date
Mailing Address _ - Validation: -
City, State, Zip
CONSTRUCTION ESTIMATE
GROUND PLUMBING
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. $
, COLL. AREA -
UNITS
ROUGH PLUMB.
1 t r
f
HEATING (ROUGH)
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
SEWER OR SEPTICTANKTROUGH
WIRING.
DUCTWORK
ROCKSTORAGE
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. p
HEATING (FINAL)
OTHER APP.IEQUIP.
t
.
GAR.SQ. FT.
GAS (FINAL)
POWER OUTLET
ROOF DRAINS
P
GROUT
DRAINAGE PIPING
CAR P. SQ. FT.
FINAL INSP.
IDRINKING
WALL SQ. FT.
WATER SYSTEM I
'
FOUNTAIN.
S.O. FT.
LUMBER GR.
'
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
( .
,
FLOOR DRAIN
_
VENTILATION
{ MECHANICAL FEES
' FIRE ZONE ROOFING•
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
FIREPLACE
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
SPARK ARRESTOR
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
GAR. ,FIREWALL
LAUNDRYTRAY
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.
SQ. FT. ® c
BATH TUB
I SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
INSPECTOR'S SIGNATURES/INITIALS
I SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
I GARDEN WALL FINAL
i SO.FT.GAR @ 3/ac
HOUSE SEWER
{
,
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECHi FEE
PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
�
t
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
I� FORMS
SEWER OR SEPTICTANKTROUGH
WIRING.
DUCTWORK
ROCKSTORAGE
R FOUND. REINF.
GAS (ROUGH)
'METER LOOP
HEATING (FINAL)
OTHER APP.IEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER I
SERVICE
FINAL INSP.
# BOND BEAM
WATER SYSTEM I
'
GRADING
cu. yd.
$:—,Plus—x$—=$
LUMBER GR.
FINAL INSP.
' FRAMING
FINAL INSP.
ROOFING
r
i
'
,
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1
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REMARKS:
VENTILATION
' FIRE ZONE ROOFING•
-
FIREPLACE
SPARK ARRESTOR
GAR. ,FIREWALL
LATHING
y,
r MESH
I
INSULATION/SOUND
t
FINISH GRADING
NSPECTION
FINAL INSPECTION-
CERT.
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
�
I GARDEN WALL FINAL
r