05262 (SFD)Ti4f 4 4 Q94(a
Building
Address 42-120 Via. $erlaosa
Owner
Abe %. Thelma Grossman
Address
W11111 t`nek e► Avo C m A
City Zip Tel.
P.O. BOX 1504
78-105 CALLE ESTADO
LA,,QUINTA, CALIFORNIA 92253
Address
77-200 Hinuezot.a
City . Zip Tela
Palm De$ert 92250 345: -5430 -
State Lic. City
& Classif. I 95Lic. #
.Arch.; Engr.,
Designer
Address Tel.
CityZip 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
I hereby affirm that I am exempt from the Contractors License Law for thefollowing
reason: (Sec. 7031.5,Busimess and Professions Code: Any city or county which requires a
permit to construct, after, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to Me a signed statement that he is licensed pursuant to
the provisions of the Contractors License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Cade, or that. he is exempt therefrom, and the basts
Ivr the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a chd 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, Suisness 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 ompiovemerns are not herded or offered for sale. If, however, the building
or improvement is said within one year of completion, the owner -builder will have the burden
.. of proving that he did not build or inprove 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 butrds or improves thereon, and who contracts for
such projects with a cofractor(s) licensed pursuant to the Contractor's License Law.)
0 1 am exempt under Sec. R- & 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
Workers 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 it 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. 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 pema7 shag 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.)
Lenders Name
Lenders 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 certity 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 authorae representatives -of this , city to enter the above-.
mentioned property for inspection purposes
Signature of applicant Date
Mailing.Address
City, State, Zip
N o . 052 -62 -
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number A,I7«.6AQ-02h
Legal Description
Project Description 4t n AR, T.as•: ?A
Sq. Ft. 2CQ� No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ .'Demolition ❑
Estimated Valuation
ti4
PERMIT AMOUNT
Plan Chk. Dep.
Plari Chk. Bal. _
Const.
Mech. 9
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
Vving %
TOTAL tq = lA4h •� r':t;'f�f
REMARKS r
YRJ irFl��#'k Y. I Lr : t44.,. A s3 `0"r ii. 4.%4'
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
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
B GRADE 3-10
w- CAI
YARD SPKLR SYSTEM
2ND FL SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. @
DUCT WORK
ROCK STORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
METER LOOP
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SQ. FT.
GAS (FINAL) 11
WALL SO. FT. ®
DRINKING FOUNTAIN
GROUT
URINAL
SQ FT ®
FINAL INSP.
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
GRADING
cu. yd.
$ plus x$
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTONDISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
VENTILATION
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
GAR. FIREWALL
SQ. FT. ® c
WATER HEATER
MAX HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® IV4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® Vic
HOUSE SEWER
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
,>S
SETBACK
OUND PLUMBING3--i�—
UNDERGROUND
A.C. UNIT
COLL. AREA
B GRADE 3-10
w- CAI
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
ER OR S3TIC NKVROUGH
WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQU1P.
REINF. STEEL
GAS (FINAL) 11
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING b 1
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING 7 ^�
MESH
INSULATION/SOUND 'I L(
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL