12786 (RPL)M1
• a f� • 1 Q
trg,
,P.O. BOX 1504 No. 12786
Building 78-105 CALLE ESTADO
Address 77-201 Calle Flora LA QUINTA, CALIFORNIA 92253
Owner
Carolyn Kinner
Mailing
Address 13240 Chalon Road
City Zip Tel.
Los Angeles, CA 90049 (310)4'72-4358
Contractor
Nomad Construction
Address
970 Ave. Madero
city La Zip Quinta, C�� 92253 Te(619) 564-0602
` State Lic.$ 628581 City 3if4
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City Zip _ (State
I
! Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirrm that I am licensed under pyoy`isions of Chapter 9 (commencing with Section
'�7 )00) of Di'vlsion,3`of the.Bus�in/ej$�s and �Pro�fessio,rn-s Code, and my license is in full force and
ect.'nrr%-iGt.v3i�f'/
'_SIGNATURE DATE
j OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 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 the applicant for such permit to rile a signed statement that he is licensed pursuant to
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
I 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 than five hundred dollars ($500).
0 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, Buisness 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.)
❑ 1, 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 of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compe. sacion Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Polic No Company
py is filed 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 less.)
I 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
NOTICE TO APPLICANT., If, 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
! ' 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
i Mailing Address
City, State, Zip
Ir\
BUILDING: TYPE CONST. OCC. GRP.-
A.P. Number
,Legal Description
Project Description Pool and Spa
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑
Demolition ❑
Estimated Valuation
$13r000.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
93.60
Const.
144.00
Mech.
24.00
Electrical
45.00
Plumbing
27.00
S.M.I.
Grading
Driveway Enc.- - '
Infrastructure
TOTAL
333.6U
REMARKS
_ No -ad is
General Contractor
on same
building.
ZONE: BY:
Minimum Setback Distances:
FINAL DATE
Issued by:
Validated by:_
Validation:
ear, Si6ilbbiftfroear11 Line
ide treet Setback from ter Line
ideLSQlt>?Ctc tor)a1�pe ine
H9
rmit
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
UNITS
/.
SLAB GRADE
ROUGH PLUMB.
YARD SPKLR SYSTEM
2ND FL. SQ. FT. @
HEATING (ROUGH)
STORAGE TANK
FORMS `
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
ROCK STORAGE
FOUND. REINF. /
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APP.IEOUIP.
DRAINAGE PIPING
CAR P. I SQ. FT. ®
TEMP. POLE
WALL SO. FT. p
DRINKING FOUNTAIN
SQ. FT. ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES.
=$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
�!`�7//
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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.
SO. FT. ® c
BATH TUB
SPARK ARRESTOR
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
LATHING
SQ.FT.GAR ® 3/ac
HOUSE SEWER
MESH
GAS PIPING
PERMIT FEE
INSULATION/SOUND
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.IEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
l
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
�!`�7//
REMARKS:
VENTILATION"'/
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION 7
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL :d