05366 (RR)4
P.O. BOX 1504 N o .
Building 78-105 CALLE ESTADO
AdflrPcc 91—ASt'l-OT10713111my" LA QUINTA, CALIFORNIA 92253
Owner
BUILDING: TYPE CONST. _ OCC. GRP.
Address BOX bb
City lZip Tel.
Contractor
city
State Lic-I City
& Classif- ,.,, ------ Lic. #
Arch-, Engr.,
Designer
Address Tel.
City I
Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
77000) of Division 3,pf the Business and Professions Code, and my license is in full force and
effect- .1 IX
SIGNATI1mE a.w ••x .. - - - ,i',� f DATE
OWNER -BUILDER DECLARATION
hereby affirm that I am exempt from the Contractors License Law for the following
reasor[ fSec 7031.5,Busbess 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
ragries the appica t Aw such permit to fie a signed statement that he is licensed pursuant to
the pmri9vs of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
nivision 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 cvi permNy of rot more than rive 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. 7044, Suisness and
Professions Code: The Contractors License Law does not apply to an owner of property who
bids or improves Oneeon and who does such work himself or through his own employees,
provided tbid such ftwovements are not intended or offered for safe. If, however, the building
or inprovenent is sold wihin oro year of completion, the owner -builder will have the burden
of provig the! he cW not bad or improve for the purpose of sale.)
❑ 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
roes not appy 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
Date owner
WORKERS' COMPENSATION DECLARATION
1 herety affirm that I have a certificate of consent to self -insure, or a certificate of
Workers Compersation Insurance, or a certifieq.capy,thereof. (Sec. 3800, Labor Code.)
Policy No. Com '
i ,
Pant �" . fes' Y
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(nus section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
1 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: 9, after making this Certificate of Exemption you should become
sutrject to the Wodrars' COurpesatbn 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.)
Lenders Name
Lenders Address
This is a building permit when property filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
1 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
construdiork 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
Number 774_.,X_1r,_n?(%
Description
Project Description 4=14_44109!
s
Sq. Ft.
Size
No.
Stories
05366
No. Dw.
Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
3timated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const. 414 On
Mech.
Electrical
Plumbing
S.M.I. a
Grading
Driveway Enc.
Infrastructure
TOTAL 4
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: Date2/15/89 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL SQ. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT. @
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING.
MOBILEHOME SVC.
BAR SINK
POR. gp, FT. ®
GAS (ROUGH)
METER LOOP
GAR. Sp, FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I Sp. FT.
GROUT
WATER HEATER
WALL Sp. FT.
FINAL INSP.
DRINKING FOUNTAIN.
BOND BEAM
WATER SYSTEM
URINAL
FT ®
=$
LUMBER GR.
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
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
FIRE ZONE ROOFING '
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FIREPLACE
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4C
HOUSE SEWER
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 I 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 SIGNATURESIINITIALS
GARDEN WALL FINAL