10938 (RER)`TT.
P.O. BOX 1504 Q. 10938
E
Buildir•.�j�. 7&105 CALLE ESTADO
Address 48-533 Via E%2ci nto LA QUINTA, CALIFORNIA 92253
Owner`
PctR Pug BUILDING: TYPE CONST. OCC: GRP.
Mailing
Address same- as above
A.P. Number
City Zip Tel.
�a ¢u.inta 92253 564--1958 Legal Description
Contractor Project Description
Vwner /Builder
Address 33 x 43 Glass Block window added to
master bath,
City Zip Tel.:
State Lic. City
& Classif. Lic. # Sq. Ft. No. No. Dw.
Arch., Engr.,. Size Stories .. Units
` Designer New ❑ Add ❑ Alter ❑ Repair ❑ -Demolition ❑
Address 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 is in full force and
effect.
_SIGNATURE DATE
OWNER -BUILDER DECLARATION Estimated Valuation
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
permit to construct, atter, 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 PERMIT AMOUNT'
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 Plan Chk. Dep.
Xsu /ects the applicant to a civl penally o/not more than rive hundred dollars.(8500). Plan Chk. Bal.
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 Const. .�
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,. Mech.
.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-bufider "I have the burden Electrical "
of 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- Plumbing
struct the project. (Sec: 7044, Business and Professions Code: The Contractor's License Law A
does not apply to an owner of property who builds or improves thereon; • and who for S.M.I. V
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading
lJ I am exempt under Sec. B. & P.C. for this reason
d Driveway Enc.
Date Ow�� Infrastructure
A' 'r w t,{r P, 1
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 4v
O Copy.is filed with the city. O Certified copy is hereby furnished.
TOTAL I5. 5
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. r �� r ;A
Date. OwnP' r� �r �a4'`�r4�. -ve/A
NOTICE TO APPLICANT: Il; after making this Ceff�cate of jEremptkm ,ydu should''b"c`a
subject to the Workers' Compensation provisions o/ the `Labor Codeyyou must 'forth
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
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 read this application and state that the above information iscorrect.
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
REMARKS
AA
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
r
1ST FL. SO. FT. ® $
2ND FL. SO. FT.
POR. SO. FT. ®
GAR. SO, FT. ®
CAR P. SO. FT.
WALL SO. FT. ®
SO. FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOMESVC.
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
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
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
BOND BEAM
SO. FT. ®c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/. c
SEWAGE DISPOSAL
LUMBER GR.
SO.FT.GAR ® 3/ec
HOUSE SEWER
F AMING
FINAL INSP.
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
1
MICRO FEE
MECH.FEE PL.CK.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.
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.
F AMING
FINAL INSP.
ROOFING
/1
vvv
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL