10551 (PLBG)Addrress di ` 2-221 VILLA
ryZlp Tel.
LA ClU13TA 92253 14—
ntractor
Aaaress
P 0 Bog 192
City JzIp Tel.:
State Lic. I City
& Classif. 480961 Lic. ff
Arch., Engr.,
Designer
Address Tel.
P.O. BOX 1504 N 0. 1 O;) Z.1
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253 ` " "l•„
J(.(/L�
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
-3614 lLegal Description
Project Description cirTayFyintiTztrp
City izip ( State
Lic. H
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed undeffprovislo a of Chapter 9 (commencing with Section
7000) of Division 3 of the Bualneserend Profeselo_ ne Code, and my license Is In full force and
effect. d •'eIDNATl1RE �^•"' .+ i-••��a• t DATE
OWN ER -BU ILDEA, DECLARATION
I hereby affirm' het I am exempt from the Contractor's License Law for the follo•wing.
reason: (Sec. 7031.8,Buslnesa;and Professlons Code: Any city or,county which requires e
permit to construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance also
requires: the applicant for such permit to file a signed statement that he Is licensed pursuant to '
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 700.3) 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 civil penalty -of not more then live hundred dollars (S500).
❑ 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, 'Bulsness and
'Professions Code: The Contractor's 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 Improvements are not Intended or offered for sale. If, however, the building
or Improvement Is sold 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.)
O I, se owner of the property, am exclusively contracting with licensed contractors to con•
struct the project. (Sec. 7044; Business and Professions Coder The Contractor's License law
does not apply to an owner of property who builds or. Improves 1 thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Lew.)
113 1 am exempt under Sec. B:'& P.C. for this reason
Date Owner
WORKERS' COMPENSATIONDECLARATION
I hereby affirm that I have a certllibate of consent to self -insure, or a certificate of
Worker's Compensatlon:Insurance, or -a certified copy thereof. (Sec..3800, Lebor.Code.)
Pol l oy' No. Company
Copy. Is flied with the city. •.. ❑ Certified copy is hereby furnished.
-.,
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars ($100) valuation
'or 1888.)
I certify that In the performance of the work for which this permit Is Issued; I sha11 not
employ anyparson In any manner so as to become subject to the Workers" Compensation
Laws of California.
Date " Owner "
NOTICE TO APPLICANT: It, alter making. this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labo'r 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 aency. for the. performance of the
work for which this permit Is Issued. (Sec. 3087, 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 thIa application and elate that the above Information Is correct.'
I agree to comply wlth'all city and
county ordinances and slate laws relating to building .
construction, and he
authorize representatives of this city to enter the above.
mentioned property for Inspection purposes.
Signature of applicant Date''
Melling Address
City, State, Zip
Sq, Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair❑ -Demolition.❑
stlmated Valuation
$
PERMIT
AMOUNT •
Plan Chk. Dep.
Plan Chk. Bal.
onst.
Const.-
Mech. `
Mech..
Electrical' '
Plumbing
$30-00-
S.M.L .
S.M. 1
_'$30-00-
Grading
Driveway Enc.
Infrastructure
TOTAL
$30.00
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—Permit-
Validated
atePermit'Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
2ND FL. SQ. FT.
POR. SQ. FT. ®
GAR. SQ. FT. ®
CARP. SQ. 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
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ic
HOUSE SEWER
REMARKS:
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
SEWERg44>RNK
ROUGH WIRING.
DUCTWORK
ROCKSTORAGE
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
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
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CONTRACTOR
PLAN FILL
RBNARKSI
LICENSE -TYPE
THIS FIIRMIT SMALL, 11CCOME! VOlO IT WORK 16 NCI? COMMENCED WITHIN 40 DAT11. CXO6ATIOvII
OI WORK TOA 120 DAY# !HALL AL= CAUDL ►E74NIT TO RIECOMM VOID,
1 Ht"BY AGRCE 701ST ALL 11024 IN CONNECTION WITH 7H17 PERMIT WILL RE 00x! IN 1LCORDANCw'11ITN TVs
LAWS Of RiVEAt109 C4UNTT AND THE STATE 01 CALS:OMMIA. 1 ALSO'AtiCE TO CARRY COMPENIATIOR
'
ANCE UPON MT E11f10T991. COMPLIANCE VITO LAWS Of THE NATE OF CALIPORMSA COYSRIItf CONTAAcloas t9 .
ALSO GUARANTEED,
'
OWNER
CONTRACTOR��'
NAILJRO ADD,
MAILING ADD,
POST OFFICE
}OST OFFIc[ _ .
TEL. BY
TIEL BY
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