12130 (PLBG)4P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 54-110 He-rrera LA QUINTA, CALIFORNIA 92253
Owner
General 3scrow
Mailing
Address 44900 San Pablo Ave.
CityZip Tel.
Palm Desert, C 92260
i Contractor .
Rick Stevenson/M Plumbing,
Address
i 74310 VelaX'do Dr.
City p Tel.:
Palm Desert, CZi92260 341-9224
State. Lit'
City
&Clas_sic. C36 302396 Lic: # 2813
-Arch., Engr.,
I Designer
Address Tel.
City Zip State
I 1 n Lic. #
AIC ENSED�CO Kf-;ACTO R'S,DECLARATIO N
I,hereby aft�,th t 1�[p h�censed TUnder provisions�of Chapter 9 (commencing with Section
X000) of Divis'b,(t� B,u�s`slar�d;Pro>ie�s�o �t;� o`de, and my license is in full force and
OWNER -BUILDER DECLARATION
I hereby affirm that 1 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, 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'sLicense 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).
O I, as owner of the properly, 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 !o 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.)
0.1, 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
su6h.projec(s4lth a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 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
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE �^�
(This section need not be completed 'f the pe mit is for d e hundred dol ($100) ual ation
or less.) d/ {B
I. certify that in the pe fr ormance f^thg�w� foYwhich is rrgt syissued, I shall not
employ any parsgri in any manner so as m eco�ne, ubj t`?O oFke '-Corte nsation
wsof•Eailfornra"_..� f. a 7' .��/ .7
subject to the Workers' Comp ion%p�sions of the L'alwatober-yo'u must forthwith
comply with such provisidns.or thl8 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.)
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 sof this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date -
Mailing Address
City, State, Zip
BUILDING: TYPE CONST
A.P. Number
Legal Description
Project Description --•
No. 12130
OCC: GRP.
Sewer Connect, .
Sq. Ft. `' ' No. NO. Dw.
Size Stories Units
New ❑ Add ❑ , Alter ❑ Repair,O: Demolition ❑
Estimated Valuation s i t 000 . 00
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech - '
Electrical
Plumbing 30.00
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
- !n:',� t £1.°'► S r"r �4.�it"i"r'f - CA,f1., S,;t«o�7. �.
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 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES ~
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT. @
FORMS
SEWER
UGH 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. SQ. FT.
GROUT
WATER HEATER
WALL SQ. FT.
FINAL INSP.
DRINKING FOUNTAIN
SO. FT. ®
WATER SYSTEM
URINAL
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
LAUNDRYTRAY
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.
SO. FT. ® c
BATH TUB
LATHING
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
FINISH GRADING
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
UGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND 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
s
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL