08861 (SFD)P.O. BOX 1,504
78-105 CALLE ESTADO
Palag $q 59 LA QUINTA, CALIFORNIA 92253
City Zip, - - ' - rel.
Palm Dart— 92240
Contractor
ress
p
& Classif: , --.. I Lic. #
Arch., Engr.,
Designer
Address Tel,
City IZip IState#
LICENSED CONTRACTOR'S DECLARATION .
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division'3 of the Business and,Professions Code, and my license is in full force and
effect.
SIGNATURE _✓ tw' _-. ' A �' .6'
OWN&.BUILOICR D LARATIOH
I hereby affirm that 1 am exempt from the ContractoCs License Law for the following
reason: (Sec. 7031.5;Business .and Professions Code: Any city or county which requires, a
permit to construct, after, 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
the7'provisions of the Contractor's License Law, Chapter 9 (commencing with Section .7000) of
Division 3 of the Business andiProfessions 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).
❑ 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. 7041, Buisness and
Professions 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;
plovlded that such Improvements. are not. Intended -or offered for sale.. 11, however, the building
or frripro, an Is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve fo, the purpose.ol-
❑ I, as owner of the property, am exclusively,contracting with licensed contractors to con-
struct the project. (Sec. 7011, 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:)
❑ 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
❑ Copy Is filed with the city: ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This -section need not be completed N 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, 1 shall not
employ any parson In any manner so, as toybecome subject to the Workers' Compensation
Lewd of California.
Date Owner
NOTICE TO APPLICANT: M, alter 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
Ihereby affirm that there is a construction lending agency forthe 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 it work thereunder is suspended for 180 days.
1 certify that 1 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
No. 08861
BUILDING:; TYPE CONST. OCC: GRP.
A.P. Number
Description
Project Description
. VVIOMATe n
Sq. Ft. No. No. Dw:
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair El
Demolition ❑
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
200 00
Mech. .
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
_ rS 4
. i T )TAL 1 200,, 00
REMARKS
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. SO. FT. ® $
UNITS
COLL. AREA
2ND FL. SO. FT.
YARD SPKLR SYSTEM
POR. SO. FT. ®
M081LEHOME SVC.
BAR SINK.
GAR. SO. FT. ®
POWER OUTLET
RQOF DRAINS
CAR P. SO. FT. 0
DUCT WORK
DRAINAGE PIPING
WALL SQ. FT.
DRINKING FOUNTAIN.
SQ FT ®
HEATING (FINAL)
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
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
GRADING
42 cu. yd.
y plus xs
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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
VENTILATION
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
FIRE ZONE ROOFIN
SQ:FT.GAR ® 3Ac
HOUSE SEWER
FIREPLACE
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
I
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
42 cu. yd.
y plus xs
=S
LUMBER GR.
FINAL INSP. [ ( d
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFIN
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION C
CERT. OCC.
FENCE FINAL
1NSPECTOA'S SIONATURESIINITIALS
GARDEN WALL FINAL
DSL
A
E
46-400 DUNE PALMS ROAD LA QUINTA,CALIFORNIA 92253 - (619)347-7513
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