05372 (BLCK)P.O. BOX 1504
Building 78-105 CALLE ESTADO
Artrfrncc _ . --- . ___.__._._ . LA GUINTA, CALIFORNIA 92253
Owner
FM AM BEM WUSO.N
Mailing
Address s4am
City Zip Tel.
LA QUINT& 92253
Contractor
Address
State Lic.I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City IZip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I he affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
effect.
bivision 3 of the Business and Professions Code, and my license is in full force and
effect
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law for the following
reason: (Sec. 7031.5,Busrhess and Professions Code: Any city or County which requires a
permit to construct, atter, improve, demofsh, or repair any structure, prior to its issuance also
requires the appfcord for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Conbactors 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 civi penaffy of not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code. The Contractor's License Law does not apply to an owner of property who
Maids or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -budder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project- (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) icensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & P.C. fo� s reason
r ,
/�. ''• f
Date f • •Owner
WORKERS' COMPENSATION DECLARATION l
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No Company
❑ Copy is filed with the city- ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($ 100) valuation .
or less.) i
certify that in the performance of the work for which this permit ssued,`I shall not
employ any person in arty manner so as to become subject to the Vllorkers' compensation
Laws of Califomia
Date Owner . ' ; ' .. / ✓� f `� /
NOTICE TO APPLICANT: C. after. making this Certificate 'of Exemption' you should -'become
subject to the Workers' Compensation provisions oA the 'L'abor Code, you must, forthwith
comply with such provisions or this permit shall be deemed revoked. 1
CONSTRUCTION LENDING AGENCY
1hereby 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 certity 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
Mailing Add
City, State,
No. 05372
11LDING: TYPE CONST. OCC. GRP.
P. Number fa_.nc
Legal Description
Project Description
' VALL
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
2,500
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
.c, j
REMARKS J '"
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: Date2/22 89 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
2ND FL SO. FT.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOSILEHOME SVC.
BAR SINK
POR. Sp. FT, ®
DUCT WORK
ROCK STORAGE
GAR. Sp. FT, ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEOUIP.
DRAINAGE PIPING
CAR P. I SO. FT.
TEMP. POLE
WALL SO. FT.
GR UT
DRINKING FOUNTAIN,
SERVICE
FINAL INSP.
URINAL
SO FT ®
WATER SYSTEM
ESTIMATED CONSTRUCTION VALUATION $
_$
WATER PIPING
NOTE Not to be used as property tax valuation
FINAL INSP.
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
VENTILATION
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEWPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ® c
BATH TUB
LATHING
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR @ Mc
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEF7 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 APPJEOUIP.
REIN F. STEEL
GAS (FINAL)
TEMP. POLE
GR UT
WATER HEATER
SERVICE
FINAL INSP.
ND BEAM 3�1
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
i
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL