12109 (PAT)P.O. BOX 1504 N o . 12109
Building 78-105 CALLE ESTADO
Address 54-165 Grand Traverse LA QUINTA, CALIFORNIA 92253
Owner
W1.1liam Bayle
BUILDING: TYPE CONST.
OCC: GRP.
Mailing
Address Same
A.P. Number
City
Zip
Tel.
La QuiYita, CA
92253
"
Legal Description
Project Description
Patio %Cover
Contractor
Burgess Builders
Address
81-263 Palo V�rda r•.�
City
lyndio, Cit
Zip
922QZ
Tela
347-8 31-
State Lic.
& Classif. 5 45 $ J
Cary'
tic. # z
Sq. Ft.
Size
No. No. Dw.
Stories Units
'Arch., Engr., \__1 %
Designer,�.—�
New ❑ 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. s -w 4
SIGNATURE ! DATE
OWNER -BUILDER DECLARATION
I herebyaffirm 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, after, 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 7000) 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 than five hundred dollars ($500).
I D 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.)
Estimated Valuation
��f}�
•
PERMIT -
AMOUNT
Plan Chk. Dep.
.
Plan Chk. Bal.
•
Const.
M • G
Mech.
Electrical
Plumbing
❑ 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
S. M. 1.
• lu
Grading
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
�' `C
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
REMARKS
(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 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 oI California.
`-Dale �` ,S"Owner i+k' to. r"^ : a ../'
��,yJA A '�y �y�y�?#- _�# ...`-'S,i •s- •? dll
K4T J14�r1 IC - F63 iii a �..i�
ZONE: BY:
Minimum Setback Distances: '
.-..a
NOTICE41TO APPLICANT. If, after making this Certificatgf Eiemption 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.
Front Setback from Center Line
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
FINAL DATE
Issued by:
Validated by:
INSPECTOR
Date Permit
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
Mailing Address
Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
UNITS
A.C. UNIT
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
BONDING
HEATING (ROUGH)
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
SEWER OR SEPTIC TANK
ROUGH WIRING
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
FOUND. REINFAJ
r
J
DRAINAGE PIPING
CAR P. I SO. FT. ®
HEATING (FINAL)
WALL SO. FT. ®
REINF. STEEL
DRINKING FOUNTAIN
SQ. FT. ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER HEATER
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LUMBER GR.
I LAUNDRYTRAY
AIR HANDLING UNIT CFM
FINAL INSP.
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® t+/a c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
GAR. FIREWALL
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. REINFAJ
r
J
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.
AL INSP. — —�
FRAMING
FINAL INSP.
ROOFING
'
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUNO
FINISH GRADING
AL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL