08086 (SFD)Building
Address
Owner
�i
mailing�
Address i
City
Con
Contractor
Owl
Address
City
State Lic.
& Classif.
Arch., Engr.,
Designer
Address
City
I herebyy�affirm
7000) qf-Division
- � 7 L
that I am
Zip ITel.
Zip
ICity
Lic. #
Tel.
Zip (State
Lic. #
Gr 'J
P.O. BOX 1504
No. 084756
78-105 CALLE ESTADO t�
LA QUINTA, CALIFORNIA 92253 Vv
h , BUILDING: TYPE CONST. OCC: GRP.
A.P. Number 769+040-OA8
Legal Description Brock E#(x: s
Project Description wool 13 Lot 28
DECLARATION
N Chapter 9 (commencing wy'th Section
;ode, rid my license is,in-(+tll force and
OWN ER -BU ILDER`DECLA RATION
(.hereby affirm that I am exempt from the Contractor's License Law for the following
reason (Sec. 7031.5,Business and Professiom -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 file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) or
Division 3 of the Business and Professions Code, or thathe is exempt therefrom, and the basis
for the alleged exemption. Any violation or 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, 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.)
E I, asowner 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.)
E I 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 Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
C�Copy is filed with the city. ❑ Certified copy is hereby furnished.
A
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 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 of California.
Date Owner
NOTICE TO APPLICANT., If, after making this Certificate or Exemption you should become
subject to the Workers' Compensation provisions or the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby 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
Mailing Address
City, State, Zip
T
Sq. Ft.
Size .2740
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$2W.357
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
6-A
Const.
pQ 3-00
Mech.
Electrical
Plumbing
Cv
S.M.I.
07
Grading
— `
Driveway Enc.
Infrastructure
TOTAL
,fir (j
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: Date6/8190 Permit
Validated by:
Validation:
T
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS "
ROUGH PLUMB. BONDING
2ND FL. SQ. FT.
STORAGE TANK
YARD SPKLR SYSTEM
SEWE / _9 ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH) METER METER LOOP
HEATING (FINAL)
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
DRAINAGE PIPING
CAR P. SQ. FT. ®
FINAL INSP.
WALL SO. FT.
WATER SYSTEM
FINAL INSP. //; �?,
FINAL INSP.
DRINKING FOUNTAIN
SO FT ®
LUMBER GR.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
U K. T � /o -�% 90 QPM
P��O..d/6�p0� l
CE)
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
FIREPLACE
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
FINAL INSPECTION
SQ.FT.GAR ® 3/ac
HOUSE SEWER
CERT. OCC.
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
UND PLUMBI UNDERGROUND
A.C. UNIT
COLL. AREA
ktlk�SLAB GRADE
ROUGH PLUMB. BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWE / _9 ROUGH WIRING
DUCT WORK
ROCK STORAGE
UND. REINF.�0�/�
!�V
GAS (ROUGH) METER METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL) TEMP. POLE
GROUT
WATER HEATER SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
FINAL INSP. //; �?,
FINAL INSP.
GRADING
cu. yd.
$ -plus-x$_=$
LUMBER GR.
l/ -FRAMING 440 /0
1 vi ROOFING /Q 1S 9,'DW�A
U K. T � /o -�% 90 QPM
P��O..d/6�p0� l
CE)
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
yfc GAR. FIREWALL )-.0 10
LATHING /O 50 -yo lemt
MESH
INSULATION/SOUND/O-2�-9
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
BN FORM 116 1_
BIA FORM 1486 ' I!
I
INSULATION CERTIFICATION ;Ire
This is to certify that, in conformance with the current energy regulations (California Adminis-
trative (ode, Title 25, State of California') and approved plans, insulation has been installed in
the building located at: I
LA OUINTA RIVERSIDE
city county
569 —30_5' GRAND TRAVERSE AVENUE 1?9 25389
Street No. (If Available) Street Lot Number Tract No.
DESCRIPTION OF INSTALLATION
ROOFS
Type of Material Manufacturer Thickness—R Value*`
EXTERIOR WALLS OWENS CORNING 6 ''1z 19
Type of Material FIBERGLAS BATTS Manufacturer FIBERGf .AS Thickness3—S /$_'R Va:oe**13
(Or Trade Name)
CEILINGS
BAITS: FIBERGLAS BAITS
Type of Material Manufacturer_
(Or Trade Name)
SQ. Ft. Covered
BLOWN:
Type of Material Manufacturer_
(Or Trade Name)
OWENS CORNING
FIBERGLAS
Wt./Bag SQ. Ft Covered R Value**.
FLOORS
Type of Material Manufacturer_
(Or Trade Name)
SLAB ON GRADE .
Type of Material Manufacturer_
(Or Trade Name) .
Width of. Insulation Inches
FOUNDATION WALLS (if required)
Type of Material Manufacturer_
(Or Trade Name)
REMARKS (if desired)
1211 38' �-
:n
Thickness 91211 R Value** 30
Thickness_ No. Bags
Thickness R Value**
Thickness R Value**.
Thickness—R Value**
General Contractor (Builder) M J BROCK & SONS, INC. License Number,
By Title Date
Sub -Contractor (Insulation Applicator) Accent Insulation Company License Number 274283
(Insulation. Masan tc.) (State "SAME" if same as C.W. troc4tr)
By Title Date 10-27-90
('California AdministroKre Code, Energy Insulation Standards, dectorea, EXCEIr r kom Sac. I9975 of the Health and Safety Coda of the State
"Compliances Upon cempleGen of the installalion of insulation. a cord *f California
ce,tifyiag that Me insulation hos been installed In conformance with the
reaulnmenh of these r*gulotiens shall be completed end ececuted by "Ne certificate of occupancy w temper ow%ficellen that a oe..ly cen-
the Insulotiow eopticater and by the bvildor. This In-olation eempGoace atrvcted Motel, metal, oportment house. Nemo or &"w residential
card shell be vetted at a conspicuoua location srithlo the 4.elling."1 al—fline Is habitable shall be issued by suds a building departmwst
anl*ss tho sMuclvm at I*psl satisfies tho minimum energy Iltaalalion
("t Valu* Is f6* measure of the resistance of at materbl er building standards established pursuant to this chapter."
compon*ntto the passage of heat, The rawlstaace velw (II of moss -typo
In Wlo6enr shall net Include eny value for renecfiv* facing.)
Form 116 --0 BUILDING NEWS, INC., 3055 Ondand Ave., Los Angeles. Calif. 9DO34-4213)87D-9811
Form 1486-0 BUILDING INDUSTRY IISSOCKT10N Of CALIFORNIA, INC., 1571 Beverly Blvd., Los Angeles, Calif. 90026—(2131625-5771