05234 (SFD)4 V
P.O. BOX 1504 No. 05'234
Building LA QUINTA8-105 CCALIFORNIA92253
Address 48-141 Vi�'. HeTffiati,il . «
Owner
Mailing 9010 Corbin avenue, Suite 3 ,
Address
City Zip Tel.
os ar d>,;e 91324 X35 --349-5i 9
Contractor a
77-200 Minnesota �
Zip I Tela
FAAM AJPq1Prr civ f ,.. A R
State Lic.. City
& Classif. Lic. # . .
D 3 2
Arch., Engr.,
Designer
Address,- I Tel.
City I
Zip I 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. , f�tr-rr.i'..•... ,/' _.,: _ .r:--._�,..a<.�a � r A�- -
t'SIGNATURE""""."•'^^%a",..:,-...-d/c.,-1K F..w wr `L. .!"�./ �= .DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.S.Bbsemss 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 peed to fie a signed statement that he is licensed pursuant to
the provisions of the Contractor's license Law, Chapter 9 (cormnencing with Section 7000) of
Division 3 of the Business and Professons Cade, 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 (E500). .
O 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 C inhaclar's License Law does not apply to an owner of property who
builds or unproves thereon and who does such work himself or through his own employees,
provided that'such improvements are not untended or offered for safe. If, however, the building
or improvement is sold within one year or completion, the owner -builder wig have the burden
of proving that he did not build or kMmve 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 fs) fcetsed pursuant to the Contractor's License Law.) -
O 1 am exempt under Ser~ a_ & 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
O Copy is filed with the city. O Certified copy is hereby fumished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the penrul is for one hundred dollars (5100) valuation
or less.)
I certify that in the performance of the 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 APPIJCANT: 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 peed 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,.Chia Code.)
Lender's Name
Lender's Address
This is a building permit when property 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 henry authorize representatives .of this city to enter the above
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
BUILDING:,TYPE CONST. OCC: GRP.
A.P. Number.
Legal Description /_A-
Project Description
6 I7--6AO -£ftp t
4UAI - DO
'-Pi,xi 2RR T..ftt_ A
ah- a�
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Sq. Ft.
Size -1950
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑
Demolition O
Issued by:
Date12/39/85 Permit
Validated by:
Validation:
Estimated Valuation
$100,923
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
it
3 Gr 4
Const
1 QA.
Mech.
Electrical
ek 44
Plumbing
CIA AA
S.M.I.
_
Grading
Driveway Enc.
Infrastructure
.
TOTAL
A3.418;.20
�/:.`�^` .�
REMARKS
1W WQ �,Sy:+i,-.110�04 5 ', S x 1010
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:
Date12/39/85 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT. @
ORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SO. FT. ®
FINAL INSP.
WALL SQ. FT.
WATER SYSTEM
DRINKING FOUNTAIN.
GRADING
cu. yd.
$ plus x$
=$
URINAL
SO FT ®
FRAMING '0yD
FINAL INSP. /
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
REMARKS:
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
LAUNDRYTRAY
AIR HANDLING UNIT CFM
SPARK ARRESTOR
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
INSULATION/SOUND
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® V4c
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
SETBACK
NO PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
ORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL) V17
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP. l/
FRAMING '0yD
FINAL INSP. /
ROOFING 2
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