MFD5 (002306)P.O. BOX 1504 No.. 0
Building 78-105 CALLE ESTADO
Address !jJ 100 hMs� �`A QUINTA, CALIFORNIA 92253
Owner - _. . , _.. .. _. , - -.. .- .. , . •. . _ .. .
Jahn Wanllkwl
. .... .
BUILDING: TYPE CONST, - OCC: GRP,
Mailing
Address P.O. Box 70415 _ _ A.P. Number . 773-078-033
City Zip JTel.
94086 73i,;9579_,. Legal Description lot .19 .
ContractorProject Description A&
..Address
_ _... Zip .... Tel..
ti
State Lic.
City
' & Classif. ..
Lic. #
Sq. Ft.
No. No. Dw.
•
Size
Stories -Units
Arch., Engr.,
Designer' _
New ❑ Add ❑
Alter ❑, ' • 'Repair '. Demolition ❑
Address
- .. _ . _ ..
Tel.
.. ..
4.,
lathe and r e{r�..[r13rttar t trv::• ,
1�� bn9Vs� '
.City
... .. ... _.
Zip
.... _ ... ..
State
.Lic: #
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LICENSED CONTRACTOR'S DECLARATION
�r. ••
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 Contractor's License Law for. the following
Estimated Valuation
�Ah 00A,
c J40.i�I113.
.-,.reason: (Sec. 703 1.5, 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) or
' 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). -` • '' •
❑ I, as owner of the property, or my employees with wages as their sole compensation,.will • -
do the work, -arid 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
-
..
• • 'PERMIT, AMOUNT '
r_F.
-Plan Chk. Dep.
.. _ - - _. ^
Plan .Chk. Bal..
_
COohm. -
Mech.
-
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.) ..
'Electrical •
-.
-
Plumbing
.0 1, as owner of the property, am exclusively contracting. with licensed contractors to con-
struct the project. (Sec. -7044, -Business and Professions Coder 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) licensed pursuant to the Contractor's License Law.)-
❑ 1 am exempt under Sec..B. B. & P.C. for this reason
S.M.I.
-
Grading
Driveway Enc.
r' X211 �1 <. �c
Dale Owner �.� � t«..� %��-++�•c. �.. d �f,�r'+.:.i
Infrastructure
WORKERS' COMPENSATION DECLARATION
' Thereby 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 '
• :. 0. Copy is filed with the city. , ❑ Certified copy is hereby furnished.
TOTAL
I A"? t IAS,
REMARKS
• CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPEN SATIO N INSURANCE
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-
(This section need not be completed if the permit is for -one hundred dollars ($100) valuation
or less.) .. - _
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: If, 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 permit shall be deemed revoked.
ZONE: BY:, '
Minimum Seftiack Distances: --
- -
_
Front_Setback from Center -Line ,-
Rear Setback from Rear.Prop.-Line '
cofusTRucnoN LENDING AGENCY
heieby affirm that there is a construction lending agency for the performance of*the-
- work for which this permit is issued. (Sec. 3097, Civil Code.) .. ., t ..
- -' -
Side Street Setback from Center Line'
'
Side Setback from Property Line '
Lender's Name
:FINAL DATE
,Issued by:'-
Validated b
Validation:
2 6.-3,
INSPECTOR'
�> �L1tP'
Date erfTllt
- .. • _
-
4 .. 1-6 .. _ 1. (,• 3;• 3 1 Sl
Lender's Address
This is a buildingpermit when properly filled out, signed and validated, and is subjecrto
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 andcountyordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the •above•..•
mentioned property for inspection purposes. :I \
Signature of applicant_ Z^ J. + '1 %' - •- .:_ ��'Date
Mailing Address - •'1 `� -�
City, State, Zip
HARD COPY
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUhiliING FEES
1ST FL. SO. FT. ® $
2ND FL. SO. FT. ®
POR. SQ. FT. ®
GAR. SQ. FT. ®
CAR P. SO. FT.
WALL SQ. FT. ®
SQ. 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
ROUGH PLUMB.
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
ROCK STORAGE
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
OTHER APPJEQUIP.
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
WATER SYSTEM
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR Q 3/ac
HOUSE SEWER
FINAL INSP.
-
ROOFING
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.
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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