12083 (BLCK)4
P.O. BOX 1504 No. 12083
Building 78-105 CALLE ESTADO
Address 53-960 Montezuma LA QUINTA, CALIFORNIA 92253
Owner
Jack Wilson
Mailing BUILDING: TYPE CONST. OCC: GRP.
Address Same
A.P. Number
City Zip Tel.
%8 Quinta, CA 92253 Legal Description
Contractor Project Description 300 >: of 5; high block . Waii
Dodco
Address
P.O. Box 1012
city Z,
CA 219l.
2253 Te
La564-6478
State Lic. City
& Classif. 397834 Lic 44�75 Sq. Ft. No. No. Dw.
Arch., Engr., Size Stories Units
Designer New ❑ Add ❑ Alter O Repair ❑ Demolition ❑
Address Tel.
City Zip State
.� Lic. #
LICENSED'CONTRACTOR'S DECLARATION
I hereby affirm thatd am lice"r d d under provisions of Clpter 9 (commencing with Section
7000) of Divisioq.3 o(,the`,Buf'iness and Professions -Code, and my license is in full force and
effect/.
SIGNATURE DATE
OWNER -BUILDER DECLARATION Estimated Valuation6 4c3ra (�8
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, 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 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.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
O I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const.• 5i3
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 -builder will 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 •
does not apply to an owner of property who builds or improves thereon, and who contracts for .S.M.I.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading
❑ I am exempt under Sec. B. 3 P.C. for this reason
Driveway Enc.
Date Owner Infrastructure
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
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 lhg work for which this permit is issued, I shall not d a •9L11�•re [ k�ta) rid* 1� �Q
employ any person in any manner so as to become subject to the Workers' Compensation .
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances:
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.) Side Setback from Property Line
Lender's Name
Lender's Address FINAL DATE INSPECTOR
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. Issued by: Date Permit
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. Validated by:
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
2ND FL. SQ. FT.
ROUGH PLUMB.
YARD SPKLR SYSTEM
FOR. SO. FT. p
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
DUCT WORK
ROCK STORAGE
DRAINAGE PIPING
CAR P. SO. FT.
METER LOOP
HEATING (FINAL)
WALL SQ. FT.
REINF. STEEL
DRINKING FOUNTAIN
SO FT @
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER HEATER
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FRAMING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
ROOFING
LAUNDRYTRAY
AIR HANDLING UNIT CFM
REMARKS:
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1+/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
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
r
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMSA�
/
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 LO &�?
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
�
/�y � '?I.� G%f
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION vL
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL