05855 (AMUS)115E- e L t= Sc 40 0 L P.O. BOX 1504
Building' / 78-105 CALLE ESTADO
Address #9 &tS,E 4.5-975 DIME PALM- LA QUINTA, CALIFORNIA 92253
CyARY HOPMS
Mailing
Address SAM
City Zip Tel.
DA QtUIM - 1 92253 1
il` NWBU'ILSDER
State Lie. I City
& Classif. Lie. #
Arch., Engr.,
Address
CityI Zip I State I
Lie. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
=01 Division 3 of the Business and Professions Code, and my license is in full force and
SHiNA711RE DATE
OWNER -BUILDER DECLARATION
I hereby affirin that I am exempt from the Contractors License Law for the following
reason: (See.7031.5,13uffiress and Prolossiona Cbde: Any oay or comity whfrh requires a
penia to. cona0mct, ager brprove, damalLrh, or repair my a mcf,", pm► to its Issuance also
marirequinis a ms of the for Me
/ars, Chapteralgried r99 (commement ncing � S�ecflopursuant
0 0 0
Dtvfsian 9 of rhe Business aria Professions Code, or that. he Is exempt tharelmm, and the basis
hor rhe ;Raped eviempdm. = ,A3t,1vn of Section 7091.5 by 'arty apAcant for a pemmil
sugleds rhe eppgt�m.to a d.g penally of rut more therm five hundred dollars ($500).
❑ 1, 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, Bulsnass and
Professions Code: The Comractors Lkewe Law does not appy to an owner of property who
bmdAds or Mprores therson and who does suchwovk herself or through his own employees,
provided cwt arrCh iniprovenrenfs are not Infended or offered for sate. #, however, the building
or 6rrprovement Is sold. within one year of completion, the owner -builder wig have the burden
of pm*V that he did not build or improve for the purpose of.sabe.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct
oo-struct the project. (Sac. 7044, Business and Professions Code: The Contractor's License Law
does not appy to. an .owner of Prop" who Lands or inwroves thereon. and who contracts for
such projects with a contractor(rt) licensed pursuant, to the ConbacEor a License taw.)
❑ 1 am exempt under Se a, & P.C. for this reason
r ' ` °-
Oats f.. t 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 copy thereof. (Sec. 3800, labor Code.)
Policy No. Company
❑ Copy is flied with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EKEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(1>section need not be completed #'the Pemhs Is for are hundred dogma ($100) va1millon
I certify that in the performance of the work for which this permit is Issued, I'shall not
employ airy person in any manner so as to become subject to the Workers' Compensation
Laws o &yiitemia
Da —0—
NOTICE TO APPLICANT: N after malmrg this Certificate of ExenWdon you shordd become
srdyed to Me tNbrkars' Ca»pensaCan provknans of the Labor Code, you must forthwith
CWWy WO such Wovlsons or ties P~ shall be deemed revoMed.
h
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, Cha Code:)
Lenders Name
Lender's Address
This Is abuilding permit when property,Hlled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 1110 days.
1 certify that 1 have read this application and state that the above Information Is correct.
letocomply 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 inspectionpurposes.
Signature of spplicani Date
Mailing Addrasa _
city, state, zip
No. 05855
BUILDING: 'TYPE CONST. OCC: GRP.
A.P. Number 613--431-011
Legal Description
Project Description COU MWIL/DRIVOG RANGE
NW CORM DETNE PAMS% HO
Sq. Ft..
Size 112.15 -
No. No. Dw.
Stories 1 Units
New 9K Add ❑
Alter ❑ Repair ❑ -Demolition ❑
Estimated Valuation
56,794
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
125. 11
Const.
446.00
Mech.
39.50
Electrical
55.96
Plumbing
123.50
S.M.I. -
3.99
Grading
22.50
Driveway Enc.
Infrastructure
3,000.00
TOTAL
4,072-4 ---577
REMARKS
-- - .n '�
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 6%9/89 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. a $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SO. FT. 0
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO. FT. a
GROUT
WATER HEATER
WALL SO. 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. ?i .g
FLOOR DRAIN
MECHANICAL FEES
C
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, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER. B.T.U.
SO. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX HEATER OUTPUT, B.T.U.
SO. FT. RESID ® T% c
SEWAGE DISPOSAL
SO.FT.GAR ® 3Ac
HOUSE SEWER
FINISH GRADING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PLCK.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 APPJEOUIP.
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. ?i .g
FRAMING
FINAL INSP.
C
ROOFING
O
REMARKS:-
EMARKS:VENTILATION
VENTILATION
FIRE ZONE ROOFING;
FIREPLACE
SPARK ARRESTOR
GAR. FIREWAL
LATHING
MESH
INSULATIOWSOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'SSIONATURESII NITIALS
GARDEN WALL FINAL