05830 (RPL)` P.O. BOX 1504 No. 05830
Building 78-105 CALLE ESTADO
Address 1--765 AVE. MJA LA QUINTA, CALIFORNIA 92253
Owner
SiL"'t,€M *A BUILDING:. TYPE CONST: OCC: GRP.
Mailing
Address $m T A.P. Number 773-162-013
City Zip Tel.
LA QUMA 92253 Legal Description 1
ContractorProject DescriptionVAN POMS, INC.
POM AM SPA
Address
68-308 MUM ROAD #b
City Zip Tel
CC. 92234 324 460.
State Lic• City
& Classif. r.53-421-0.14Lic. # 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 affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of b='ion'3 of the Business and Professions Code, and my license is in full force and
effect &+' * J '
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,81sihess 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
requfres the of for such permit to rile a signed statement that he is licensed pursuant to
the provisions of the Conbactor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and ProfessionsCode, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any vfolatfon of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a cw9 penalty of not more than Ove 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 inproves thereon and who does such work himself or through his own employees,
Provided trot such inprovements are not intended or offered for sale. h however, the building
or improvement is said within 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.)
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to col.
struct the project (Sec- 7044, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent fo.self-insure, or a certificate of
Workers Compensation Insurance, or a certified¢opythereof. (Sec. 3800, Labor Code.)
Policy No Company C— t ./,l%
❑ Copy. is filed with the city. ❑ Certified copy is hereby fumished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the permit is for one hundred dollars ($100) valuation
or less.)
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
N077CE TO APPLICANT: ft, after making this Certificate of 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
1 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.)
Lenders Name
Lenders Address
This is abuilding 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 mead this application and state that the above information is correct.
1 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 Addrass
City, State, Zip
Estimated Valuation
G _ Al3C1l _ f`jr�l
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
S.M.I.
Driveway Enc.
Infrastructure
AMOUNT
27.00
by.
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback f-om Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
5/30/89
Issued by: Date Permit
Validated.by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
UNDERGROUND
r —=
IST FL SQ. FT. ® $
UNITS
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL Sp. FT.
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
ROCK STORAGE
FOUND. REINF.
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SQ. FT. ®
GAS (FINAL)
WALL SQ. FT.
DRINKING FOUNTAIN.
SQ FT @
GROUT
URINAL
ESTIMATED CONSTRUCTION VALUATION $
SERVICE
WATER PIPING
NOTE Not to be used as property tax valuation
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
FINAL INSP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
Poe (� / U� I
(r
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.
SO. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3Ac
HOUSE SEWER
LATHING
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 PLUMBING62M
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.IEOUIP.
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
Poe (� / U� I
(r
REMARKS:
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION -
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL