15692 (RR)QUM&
P.O. BOX 1504
Building49-187i205/223/241/259 78-495 CALLE TAMPICO
Address ` al ntra TE-5-1-1LA QUINTA, CALIFORNIA 92253
Address 50-147 Calle 0axi a.
City Zip Tel.
La Quina 92253
Contractor
Bir 'int' ftiversal
Address
3462 La Campana
Pala Springs r 92260 320--6022
State Lic. • City
& Classif.. .365357 Lic. # 2293
Arch., Engr.,
Designer "
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby afti-4n 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 the following
reason: (Sec. 7031.5,Business 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 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 or not more than five hundred dollars ($500).
❑ 1, 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 or 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.) "
O I, as owner of the property, am exclusively contracting with licensed contractors *o 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 contractors) licensed pursuant to the Contractor's License Law.)
❑ 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
_ Workers Compensation Insurance, ora certified copy thereof.. (Sec. 3800, Labor Code.)
Pofly'
No. -"� cx' Company Ri 19 .:.
to Copy is filed with the city, ❑ Certified copy is hereby furnished. r
CERTIFICATE OF EXEMPTION FROM '
•- WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff .the permit Is for one hundred dollars ($100) 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 APPLICANT: If, alter making this Certificate o1 Exemption you . should become
subject to the Woikers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked. -
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
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.
1 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
BUILDING: TYPE CONST
A.P. Number
No. 15692
OCC: GRP.
Legal Description
Project Description Re -roof new polyurethane
foam over existing built-up roof.
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add-❑ Alter ❑ Repairs':❑ Demolition.❑
Estimated Valuation 17..04.0.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.,
. {�
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Eno.
Infrastructure
TOTAL
REMARKS
firr `!
j
�S ' I h r11�
6- A!
y�
/ l
•,j: L!
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. PLUMBINU FEES
1ST FL. SO. FT. ® $
2ND FL. SO. FT.
FOR. SO. FT. ®
GAR. SO. FT. ®
CAR P. SO. FT.
WALL SO. FT. ®
SO. FT. ®
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 APPJEQUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
c
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.
SO. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1 Va c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/<c
HOUSE SEWER
REMARKS:
VENTILATION
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
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 APPJEQUIP.
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.
FRAMING
FINAL INSP.-
01� ROOFING
(s'
+
f
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION 3/7
CERT. OCC.
FENCE FINAL
'
INSPECTOR'S SIONATURESIINITIALS
GARDEN WALL FINAL