002863 (3&4)Building
Address
Owner
I
Mailing
Address
City
:p
Contracl
Address
City '
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Zip T Tel.
*��-�2�'
J.Eja:�a�al M=tom and iadd
Sam
I State Lic. Gity
& Classif. 2g9110 Lic. # 328.
Arch., Engr., ^
Designer
Address Tel.
City Zip State
Lic. # -
1 LICENSED CONTRACTOR'S DECLARATION ,
I hereby affirm that I am licensed under provisions of Chapter 9 (commencingwith Section
7000) of Division -3 of the Business and Professions Code, and my license. is in full force and
effect.
_ .t -
SIGNATURE ` ✓`-� - - DATE
OWNER -BUILDER DECLARATION
I hereby 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
permR 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). '
❑ 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, 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.) --
O 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.)
I
❑ 1 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. . O 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.
No. 002863
BUILDING: TYPE CONST. OCC: GRP."
A.P. Number
Legal Description
Project Description FM WN PH&CM 34 B
Plm 20 Q
2596
Sq. Ft. No. No. Dw.
Size Stories Units
New Add ❑ Alter ❑ Repair ❑ 'Demolition ❑
Estimated Valuation
179A180'00
PERMIT
Plan Chk.. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I. F
AMOUNT
633.00
Grading
Driveway Enc.
Infrastructure
2,000.00
TOTAL 3.471.23
REMARKS
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
ZONE:
BY:
subject to the 'Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked. -
Minimum Setback Distances:
Front Setback from Center Line
.
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Side Street Setback from Center Line '
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.)
Side Setback from Property Line
Lender's Name
Lender's Address
'
FINAL DATE
INSPECTOR
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
.tom7
1-2-8? Permit
read this application and state that the above information is correct.
Issued by:
Date
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.; f ��rr•
Validated by:
u^ ✓ ,
Signature of applicant % t -'•1' - Date
Mailing Address "'
Validation:
City, State, Zip
A%Z12
]. 30 3471..23 Ch
HARD COPY
T
_
CONSTRUCTION ESTIMATEA1111111111L,
NO. ELECTRICAL F -
NO. PLUMBING FEES
1ST FL. SO. FT. ®
UNITS
V LAB GRADE 2
UGH PLUMB
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT. ®
FORMS
XWER OR SMI ACR 41,OfOUGH
WIRINCa-9/-9/
/`
MOBILEHOME SVC.
BAR SINK
POR. S0. FT. p
GAS (ROUGH)
METER LOOP
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. S0. FT. ®
GROUT
WATER HEATER
WALL SO. FT.
FINAL INSP.
DRINKING FOUNTAIN
SO. FT. ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
- $
WATER PIPING
NOTE: Not to be used as property tax valuation
RAMING�.. Si
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
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
INSULATION/SOUND
SO.FT.GAR ® 3/ac
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 FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK _
ROUND PLUMBIN '
UNDERGROUND
A.C. UNIT
COLL. AREA
V LAB GRADE 2
UGH PLUMB
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
XWER OR SMI ACR 41,OfOUGH
WIRINCa-9/-9/
/`
DUCT WORK
ROCK STORAGE
,9.eleOUND. REINF. z
1
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.
NAL INSP.
RAMING�.. Si
INAL INSP. /Q . i
OOFI.N'GG� �f%OF (�
+ s I
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
ZKATHING 4/-_r0- /
MESH
INSULATION/SOUND
FINISH GRADING
INAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS.
GARDEN WALL FINAL