06080 (BLCK)Building
AAA -54-065 8errere
T4ht 4 4 Q"
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Owner I
Jack ClArk, Jr-
Address P. 0• Box 1371
City Zip Tel.
La i uirlLa 1 9225
Contractor
Zip I Tela
State Lic.I City
& Classif. Lic. #
Designer
Address Tel.
City ZipI State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I aim licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Busirless,and Professidns Code, and my license is in full for sand
effect •� . % r � Jf �. � r /'v ... '"�. +F % f
cr t
SIGNATURE ____ DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Busi7ess and Prolessions Code: Any city or county which requires a
Permit to construct, alter, ftrove, demoFsh, or repair any structure, prior to its issuance also
requires the applicant for such penr& to tie a signed statement that he is licensed pursuant to
the provisions of the Contractors 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 vlota m 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).
❑ 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, Busness and
Professions Code: The Contractors License Law does not appy 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 sok/ 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 Contractors 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
Workers Compensation Insurance, or a certified cop�r of eof. (Sec. 3800, Labor Cade.)
Policy No Company
❑ Copy is filed with the city. ❑ Certified copy is hereby fumished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not Lme completed If the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of flip 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
aliforniaDateOwner
NOTICE TO APPLICANT: ff, after making this Certificate of Exemption you should become
st4ect to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or Otis permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 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.)
Lenders Name
Lenders Address
This is a building permit when property 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
urposesSignature of applicant — Date
Mailing Address
City, State, Zip
No.
BUILDING: TYPE CONST. OCC: GRP.-.
A.P. Number 774-x213-016
Legal Description
Project Description 501 X 2&? of retai.ninit wall
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation �1,354
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
545.00
Mech.
Electrical
Plumbing
S.M.I.
.14
Grading
Driveway Enc.
Infrastructure
TOTAL
�ti�• ts1
REMARKS
x*% -71••• "'RY.r 9• i.' 'r iY^Y 1"fL' A� '�"A ra
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 7/11/89 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
•
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING,
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SO, FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I SQ. FT. ®
GROUT
WATER HEATER
WALL SQ. FT.
FINAL INSP.
DRINKING FOUNTAIN.
FT ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
=$
WATER PIPING
MOTE: 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, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER. B.T.U.
SQ. FT. ®c
BATH TUB
LATHING
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1% c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
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 FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR GOND. 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 APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
OND 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