15695 (RR)P.O. BOX 1504 No. 1 5 6 W
Building 78-495 CALLE TAMPICO
Address 49-419,433,447 'Vista Bonit&A QUINTA, CALIFORNIA 92253
Owner Santa Rosa C*Ve R.O.A.
Mailing BUILDING- TYPE CONST. OCC: GRP.
Address 50107 Calle Oaxaca
A.P. Number
City, Zip Tel.
La - Quinta '92253 Legal Description
Contractor Bryant Universal Project Description Install new poly urethane
Address - =�foam Z'G:Qf and coating over exsistIng
3462 La Cmgana
City Zip Tel.:
Palm Springs 92260 32-01-6022
State Lic.'.3535 City
& Classif. Lic. # 22.93
Arch., Engr.,
Designer.
Address Tel.
-
CitY P Zi State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm -that I am licensed under 0isions of Chapter 9 (commencing with Section
7000) of Divisidn.3 of tth+e Business and Professions Code,* and my license is in full force•and,
effect r'-` fs>•�c a"'�.� . i^}g .
SLGNATURE DATE
OWNER -BUILDER DECLARATION
(hereby affirm that I am exempt from the Contractors License law for the following
reason: (Sec. 7031.5,Busrness 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 frle 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, andthe •basis
for the alleged exemption. Any violation of Section 7031.5 by' 'any applicant for .a permit
subjects the applicant to a civil 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds of 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 knprove 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(s) Qcensed pursuant to the Contractor's License Law.)
O 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified gopy thereof. (Sec. 3800, Labor Code.)
Policy No:. -a Company /I.> c %+
❑ Copy is filed with the city, O Certified copy isherebyfurnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATIONINSURANCE
(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
Date Owner
NOTICE TO APPLICANT. N, after making this Certificate"ol 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.
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 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 is correct.
I agree to comply with all city and county ordinances and state laws -relating to building -
construction, and hereby authorize representatives sof this city to 'enter the .above-.
mentioned property for inspection' purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
built up- Loot.
Sq. Ft.
SizeStories
No. No. Dw:
Units
New ❑ Add ❑' •
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation�0,Cs5+�.Q4
PERMIT
AMOUNT
Plan Chk. Dep:
Plan Chk. Bal.
Const.
$30.00
Mech. .
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
$30000
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear r� p. Line
Side Street Setback:from Center -Line
Side Setback from'PropertyFLine.11-
;��/ `\) 7
FINAL DATE INSPECTOR -
Issued by: Date -Permit_��//��
Validated by: `\ 9`9s % �!
` f i
Validation:%
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBINij FEES
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
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 APP./EOUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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 ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/.c
HOUSE SEWER
REMARKS:
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 APP./EOUIP.
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.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING '
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL