09078 (BLCK)P.O. BOX 1504
78-105 CALLE ESTADO
Address 54-622 Herrera LA QUINTA, CALIFORNIA 92253
Mailing
Address
City
T'a .�
Contractor
a
Address
City
State Lic.
& Classif.
Arch., Engr.,
Designer
Address
City
Zip jTel.
Lic. #
Zip (State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
70 OO) of Division 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,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'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 exempfion. 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).
-, as owner of the property, or,my employees with wages as their sole compensation, will
pthe work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
rofessions 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.)
❑ I, 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
�''' �'./•l ✓fit
Date Owner a/ /
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.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPEN SATIO N 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 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 of Exemption 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.
CONSTRUCTION LENDING AGENCY
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.)
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
Waif
No. 09078
L7/7
BUILDING: TYPE CONST. OCC: GRP.-
A.P. Number
Legal Description
(Project Description
5: Block Wall
Sq. Ft.tr
Size
No, No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
�W sV6Y
650.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
25.00
Mech.
Electrical
Plumbing
S.M.I.
„0
Grading
Driveway Enc.
Infrastructure
TOTAL
25.07
REMARKS
1 ajf l yL t� ! 4 y�
`�5 # (4 A % 84& e'.gi`41_ .7 V -C A4 V
'
. V' ,(—lYEA=Yu .P �•Y .f �G4. .., c...Y�YY
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
ROUGH PLUMB.
BONDING
2ND FL. SO. FT.
STORAGE TANK
FORMS
YARD SPKLR SYSTEM
POR. SQ. FT. ®
MOBILEHOME SVC.
ROCK STORAGE
BAR SINK
GAR. SQ. FT. ®
POWER OUTLET
HEATING (FINAL)
ROOF DRAINS
CAR P. SQ. FT.
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
WALL SQ. FT.
GROUT
WATER HEATER
DRINKING FOUNTAIN
SQ. FT.
BOND BEAM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GRADING
cu. yd.
$ plus x$
_$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FRAMING
FLOOR DRAIN
MECHANICAL FEES
'.:,
ROOFING
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
9
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
SPARK ARRESTOR
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE,TEMIPERM
4"
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SQ. FT. ® c
INSULATIONISOUND
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1+/e c
FINAL INSPECTION
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ic
HOUSE SEWER
FENCE FINAL
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
1.
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. REINF.
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.
FINAL INSP.
FRAMING
FINAL INSP.
'.:,
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL