06082 (BLCK)4
P.O. BOX 1504
78-105 CALLE ESTADO
Building
Address Mai Pa;& LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address
City lZip ITel.
Contractor
Tom Stoma Masonry
Address }
52-637
City Zip Tel.
La Qnimta 92253 564-2128
State Lie. City
& Classif. 494257 1 Lic. #
Designer
Address—T—Tel
CityI Zip I State I
Lie. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
=111
Division 3 of the Business and Professions Code, and my license is in full force and
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,8usiness and Professions Code: Any cry or county which requires a
permit to construct, alter, improve, demolish. or repair any struchae. prior to its issuance also
requires the applicant for such permit to lir® a signed statement that hes licensed pursuant to
the provisions of the Contractors L.iconse law, Chapter 9 (commencing with Section 7000) of
OivLsion 3 of the Business and PrWesgons 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
sutifeds the applicant to a crvi penally of not more than five hundred dollars f$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, 0uisness and
Rofessians Code: The Contractors Lioese Law does not apply to an owner of property who
Dulls or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for safe. It, however, the building
of irprovement 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.)
O 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project (Sec. 7044, Business and Wofessions Code: The Contractor's License Law
does rwt apply to an owner of property who bu17s or inproves thereon, and who contracts for
such projects with a confractor(s) icersed pursmart to the Contractors License Law.)
❑ 1 am exempt under Sec --------R a P.C. for this reason
Date owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sac. 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 of be completed 9 the pend is for one hundred dollars ($100) valuation
of less.)
I certify that in the performance of ttip 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 f, after mabig Ihis Certificate of Exertption you should become
subject to the Worsens' compensation provisions, of the labor Code, you must forthwith
comply with such provs)ons or this pend shat be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued- (Sec- 3097, Civ? Code.)
Lender's Name
Lender's 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.
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
No. 06082
BUILDING: TYPE CONST. OCC: GRP.:
A.P. Number H/A
Legal Description
Project Description Block wall & viers
Sq. Ft.
Size
No. No. Dw.
'Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing ,,,_„_„_,_,,,,,..
S.M.I.
/ r
Grading
/
Driveway Enc.
Infrastructure
TOTAL
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 INSPEE7rO�R
Permit
Issued by: —Date_Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST 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. SQ, FT. ®
GAS (ROUGH)
METER LOOP
GAR. SO, FT. Q
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I SQ. FT. ®
GROUT
WATER HEATER
WALL SQ. FT.
FINAL INSP.
DRINKING FOUNTAIN.
SQ FT ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
=$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
VENTILATION
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1+/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
HOUSE SEWER
FINISH GRADING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FiF7 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
r/
FOUND. REINF// 9—
R' I
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
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/
P ��, `�
9A (J� r3 6
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
)