04101 (3&4)[Address
Qum&
P.O. BOX 1504
lding 78-105 CALLE ESTADO
54-785 Firestone LA QUINTA, CALIFORNIA 92253
Mailing
Address
City
Palm I
Contractor
tin t;'L n
Address
City
State Lic.
& Classif.
Arch., Engr.,
Designer
Address
75-005 Country Cl" Drive -
Zip Tel.
ese t: 1 92260 568-282
Zip
City
2881,,3 Lic. # .. 328
Tel.
City (Zip (State
Lic. #
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 isvn full force and
effect.. 1^ r`: n -.y( .' !'` �� _} /vI
SIGNATURE - DATE
OWNER -BUILDER DECLARATION
I- her affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. ;7031.5,Business 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 9 (commencing with Section 7000) of
Division 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 civil penalty of not more than five hundred dollars ($500).
O 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, 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,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
or proving that he did not build or improve for the purpose of sale.) .
❑ I, 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
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.)
O 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
1hereby 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 if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
Thi$ 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
11LDING: ,TYPE CONST.
P..,Number M West
OCC. GRP.
041-01
,Legal Description
Project Description -
w'�'�9ts sii 1873, Plart 30CR
Minimum Setback Distances:
Front Setback from Center Line
Sq. Ft., , 2826.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Side Setback from Property Line
FINAL DATEbll�,
CT�OR
Issued by:
Permit
—Date_Permit
Validated by:
Validation:
Estimated Valuation
$194 652
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
55' • 1 U
Const.
5 To—, 5U
Mech.
�� • ii
Electrical
Plumbing?
•S 5
S.M.I.
13 ob"
Grading
Driveway Enc.
Infrastructure
—4, 38U 5
TOTAL
REMARKS
' 4ikt:�� iii d„''t`•��il'�f�"'15+�3"'#?"{"� _ �h �Ct
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 DATEbll�,
CT�OR
Issued by:
Permit
—Date_Permit
Validated by:
Validation:
City, State, Zip
WHITE' FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD -'ASSESSOR'S OFFICE, HARD COPY - FILE
r,-, ..- .. ..'.... .� .^. •. e. L --.,...... .Js {:..: .. 5. ...... ....!'1:,. .. . .ar -, ... r..... ...._. r.T .,.. _ e. .. S,r_. �- .. .. .., ,. t:� .e.,.re .�... n•,'... -..d .. _.� ..
_
NO. ELECTRICAL FEES
NO. PLUMBING FEES
Z
UNITS
SLAB GRADE
ROUGH PLUMB
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC
BAR SINK
ROUGH WIRING
POWER OUTLET
ROOF DRAINS
FOUND. REINF.
A (ROUGHi
?A'
DRAINAGE PIPING
HEATING (FINAL)
OTHER APP.IEOUIP.
DRINKING FOUNTAIN
AS (FINAL)
TEMP. POLE
URINAL
=
GROUT
WATER PIPING
ERVICF�
FINAL INSP.
FLOOR DRAIN
BOND BEAM
WATER SYSTEM
WATER SOFTENER
DOD
SIGN
WASH ER(AUTONDISH)
FINAL INSP.
GARBAGE. DISPOSAL
NDED
LAUNDRYTRAY
KITCHEN SINK
U.
TEMP USE PERMIT SVC
WATER CLOSET
POLE, TEMIPERM
LAVATORY
AMPERES SERV ENT
SHOWER
SO. FT. ® c
BATH TUB
SO. FT. @ c
WATER HEATER
SPARK ARRESTOR
SO. FT. RESID ( 114 c
SEWAGE DISPOSAL
GAR. FIREWALL
SO.FT.GAR @ 3/4c
HOUSE SEWER
LATHING
GAS PIPING
PERMIT FEE
PERMIT FEE
FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB FEE
PLUMBING ELECTRICAL HEATING 8 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.
A (ROUGHi
?A'
METER LOOP
HEATING (FINAL)
OTHER APP.IEOUIP.
REINF. STEEL
AS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
ERVICF�
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
E -Plus-X$
. $
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FI SH GRADING
IN k INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL