04114 (SIGN)•4 Qum&
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address Pa1r' Ro y a 1 a LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address P . O. 3—Ax 3A.i7oo
City Zip Tel.
I-Teyt fan,, Y, 77235 713 -661-7000
Contractor
.AJC Graphic+
Address
Ci ly Zip Tel.
:orona 31720 714--371--1717
State Lic. City
&Classif. 530684 Lic.#
Arch., Engr.,
Designer
Address Tel.
City I Zip 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.
.JIGNA7URE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Llcense Law for the following
reason: (Sec. 7031.5,Buimness and Professions Code: Any city or counly which requires a
pornill to constnrcf, alter. Improve, demafsh, or repair any structure, prior to lls issuance also
requires Vie appikanl 101 such permit to We a Signed statemanf that he is licensed pursuant to
the pmvlsions of the Cunimcfor's License Law, Chapter, 9 (carnmerning with Section 7000) of
D'vis+ur 3 of the Buskmess and Professions Code, or that ha is exempt theial o , and the basis
(or the atieged exemption. Any vieiaflan of Secfton 7031.5 by any applicant far a pomik
aubjecfs the applicant 10 a civif penalty of not Mora than five hundred dollars f$500).
f7 1, as owner of the property, or my employees with wages as !heir sate compensation, will
do the work, and the structure is not Intended or offered for sale. (Sec. 7044, Buieness afrd
Prolessfons. Cade: The Contractor's License Law does not apply to an owner of property who
builds or improves thsrean and who does such work himself or through his own employees,
provided that such frprovemants are not intended or offered fat safe. 11, however, rho buifding
or Improvemani is said wlfhin 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 to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contraclar's Ocanse Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contraclor(s) licensed pursuant to the Contractor's License Law.)
❑ I 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 aartiflcate 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.
CERTIFICATE OF EXEMPTION FROM
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 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 CerfNicars .of Examption you should become
subject to the Workers' Compensation provisions of the Labor .Code, you must forthwith
comply with such provisions or this permit shalt 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, Civil Code.)
Lender's Name _
Lender's Address.
This Is a building permlt when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
1 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 slate laws relating 10 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
Legal Description
Project Description
OCC. GRP.
Palm �,'Oyals� Sion
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const. a NO
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
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
!14 P C R
Issued by:
Date Permit
Validated by:
Validation:
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
CONSTRUCTION ESTIMATE
NO
ELECTRICAL
FEES
NO
PLUMBING
FEES
UNITS
S
tST FL SO FT rp
YARD SPKLR SYSTEM
2ND FL SO FT
MOBILEHOME SVC
BAR SINK
POR SO FT a
POWER OUTLET
ROOF DRAINS
GAR SO FT
DRAINAGE PIPING
CAR P SO FT 6
DRINKING FOUNTAIN
WALL SO FT a
URINAL
SO FT fd
WATER PIPING
ESTIMATED CONSTRUCTION VALUATION $
NOTE Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOXDISH)
APPLIANCE DRYER
-GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B T.0
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE,TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
I AMPERES SERV ENT
SHOWER
BOILER B T U.
SO. FT. a c
BATH TUB
SO FT. a c
WATER HEATER
MAX HEATER OUTPUT, B T.0
SO FT RESID B 11/4 c
SEWAGE DISPOSAL
SO FT.GAR @ 3i.c
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 8 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.IEOUIP
REINF STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP
BOND BEAM
WATER SYSTEM
GRADING
cu yd
S Plus xS
=S
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
INSPECTDR'S SIGNATLIRESIONITtALS
GARDEN WALL FINAL