9454 (SOTB)P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 48-527 Via Encs to LA QUINTA, CALIFORNIA 92253
Owner
Andrew Smith
Mailing
Address Sc3Me
City Zip Tel.
La Quiriti. 922,103 1 564-5816
Contractor
C3'cr ier/Builder
. . t
State Lic.
City
& Classif.
Lic. #
I
Arch., Engr.,
Designer
Address
Tel.
City
Zip
State '
Repair ❑ Demolition ❑
Lic. #
LICENSED CONTRACTOR'S DECLARATION • .
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
70 OO) of Division 3 of the Business and Professions -Code, and my license is in full force and
effect.
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 Cade: 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 81e a signed statement that he is licensedpursuant 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 penally of not more than five hundred dollars.(8500).
AX -as owner of the property, or my employees with wages as their solecompensation, will.
4. do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
4Professions 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
of proving that he did not build or improve for the purpose of sale.)
0 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" O 1 am exempt under Sec: B. S P.C. for this reason
Date - Owner
r^
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, ora certified copy thereof. (Sec. 3800, Labor Code.)
Policy.No. .Company '
5copy 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 pemtit is for one hundred dollars (8100) vatuation.
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: ff, after 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 .
Ihereby 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
This is a building permit when properly filled out, signed'and validated, and is subject to
expiration it 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. 9454
BUILDING: TYPE CONST. 'OCC: GRP.
A.P. Number
I Description
:ct Description • Inst-al1 fare pit in patio
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:
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New 0 Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated. Valuation
300.00
PERMIT ..
AMOUNT
Plan Chk..Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
6.00
S.M.I.
Grading
Driveway Enc.
Infrastructure
61
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 INSPECTOR
Issued by-.- Date Permit -
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL SO. FT. ® $
2ND FL SO. FT.
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. I SD. FT.
WALL SO. FT.
SO Fr. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEOUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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
SO. FT. ® c
WATER HEATER
MAX HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1% C
SEWAGE DISPOSAL
SO.FT.GAR @ V4c
HOUSE SEWER
REMARKS:
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PLCK.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.
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REIN F. STEEL
//
GAS (FINAL/�3-c?
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 SIGNATURES11NITIALS
GARDEN WALL FINAL