08673 (RR)P.O. BOX 1504 t No. 08673
Building 78-105 CALLE ESTADO
Address 47-40 LrLSENHOM LA OUINTA,.CALIFORNIA 92253
Owner RE—
Mailing IOARAi BUILDING: TYPE CONST. RO INCDCC. GRP.
Address
A.P. Number
City Zip Tel.
Legal Description
Contractor Project Description REROOFING — GRAVEL
CRNTROXIMODERN ROOFING
Address
Cityip el.'
T"RNITY T -US 9222Z— 162—A
State'Lic. City
A Classif. a
C-39 367464 Lip. # 984 Sq. Ft. No. No. Dw.
Arch., Engr., Size Stories Units'
Designer New ❑ Add ❑ Alter ❑ Repair ❑: Demolition ❑
Address Tel.
CityZip State
Lic. #
.LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
TOGO, of Division 3 of the Business and Professions Code, and my license is in full force and
effect. a
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Bualness 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 8 (commencing with Section 7000) of
Divislon'3 of the Business and Professions Cade, or that. he is exempt therefrom, and the bests
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the.appllcant to a civil penalty of not more than rive hundred dollars ($500).
El I, 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, Bulsness,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,
provided that such Improvements are not Intended or offered for sale. B,- however, the building
or Improvement is sold within one year ofcompletion, the owner -builder will have the burden
of proving that hedid not build or improve for the purposeofsale.) -
❑ I, as owner of the property, am exclusively contracting with licensed contractors to coo-
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.)
❑ 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. dT Company f E':,
❑ Copy is filed with the city. ❑ Certlfled cop�furnrshed.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION 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 pparson in any manner so as to become subject to the Workers' Compensation
Laws of Cahforni&.
Date Owner
NOTICE TO APPLICANT: It; alter making this Certificate of Exemption you should become
subject to the Workers' Compensationprovisions 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 winch 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
Plan Chk: Dep.
Plan Chk. Bal.
Const.
4146. so
Mech.
Electrical
Plumbing
S.M.I.
'Grading
Driveway Enc.
infrastructure
TOTAL
3
REMARKS
-495141 4P 47W(k
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
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SO. FT.
FORMS
SEWER OR SEPTIC TANK
POR. SO. FT. @
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. SO. FT.
OTHER APPJEOUIP.
DRAINAGE PIPING
WALL SO. FT. ®
TEMP. POLE
DRINKING FOUNTAIN.
SO FT ®
GROUT
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
h
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
REMARKS:
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.
SO. FT. ® c
BATH TUB
SO. FT. c
WATER HEATER
MAX. HEATER OUTPUT, &T.U.
SO. FT. RESID ® 1 V c
SEWAGE DISPOSAL
SO.FT.GAR ® 34c
HOUSE SEWER
MESH
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 OR SEPTIC TANK
ROUGH WIRING.'DU
ORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
M R LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL) oo
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
FI INSP.
GRADING
cu. yd.
$ -Plus-X$-=$
LUMBER GR.
FRAMING
FINAL SP.
ROOFING
h
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION -2?-.q JA
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL