12920 (BLCK)Building rlt'"ac- 'M152
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address 4 2 - 1 51.
City Zip Tel.
'Yllt:�r'Ttilda 1�.)urf:!_-[ CA 345--5,49r`
Contractor
CiIjyt1 Zip Tel..
State Lic. City
& Classif, t^_ _r 9 4 $ C 1 7 Lic. # ; r,
Arch., Engr.,
Designer
Address I Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
i,hereby affirm that I am licensed under provisions of -Chapter 9 icommenetng with Section
7000) of Div ialon 3 of the Business and Pr.l.sstbns Code, and my license is in full twee u1
effect.
iSl �N"�1IP.F DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
wasorl, (Sec. 7031.5,8usihess and Professions Code: Any city or counfy which requires a
permit in construct, alter, improve, demolish, or repair -any slructuro, pdor !o its fssuarice also
requites the applicani for such permit to fila a signed stalemari( Thal he Is Acensed pursuapf fo
fha.provlstort:%( the Cerrtraclor's License Law, Chapter 9 [commencing with Sectforr 7000) of
Dirdsmn 3 of the Business and Professions Code, or That he Is exampi therefrom, and the basis
for the alleged exemption. Any viWaflpn of, Section 7031.5 by any appAcadl for a permit
subjects Me.appticanl to a civil penally of not more than llva hundred dollars (S500).
C7 I, as own or of the property, or my amprnyoes with wages as thalr sole compensation, will
do the work, and the structure Is not Intended or Offered for sale. (Ses. 7044. Bulsrrass arrd
Professions Coda: The Conbaclors License Law does. not apply fa an.owner of propery who
buhds or bnProves thereon and who does such work himself or through his own employees,
provided that such irriprovemants are nor intended or offered for sale. if, however, the builWng
or hrrprovemenl fs soid Whin one year of corrtplefion, 1fm owner-bviidar will have the burden
of proving that he did not build or improve for the purpose of said.)
❑ I, as owner of the property, am exclusively contracting'' with licensed contractors to con-
struct the project. (Sec. 7044, Business and ProNssmr;0Code. The Contractor's Licehsa Law
does not apply to an owner of property who bugds or lmprovgs thereon, and who contracts for
such projects with a corrlractor(s) ficansed 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 certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Pafigy No Company
Jtopy 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
at tess.)
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 a§ io 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' CoMensaf an provisions of the Labor Code, you must forthwith
comply with such provisions or (his permit shall be.deamed 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 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
constructlon, and hereby authorize representatives of this clty to enter the above.
mentioned property for inspection purposes.
Signature of applicant- Date
Mailing Addres
City, State, Zfp
No. 12 -:20
BUILDING: TYPE CONST. OCC. GRP.
P. Number
Legal Description
Project Description } - ' - %IT 1 ib,,
n
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation 1 r ;; 4 ;' . 0 0
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances: z. _
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 Permlt
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO.
ELECTRICAL FEES
NO.
PLUMBING FEES
1ST FL
2ND FL
POR
GAR.
CARP
WALL
ESTIMATED CONSTRUCTION
SQ. FT, g
SQ. FT, C)
SQ, FT. @
SO. FT. @
SQ. FT. r�
SQ. FT. @
SQ. FT. r�
VALUATION
$
UNITS
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
$
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
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
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.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 1/ac
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES MICRO FEE
MECH.FEE
FPL.CK-FEE
CONST. FEE
ELECT. FEE
SMI FEE
PLUMB. FEE
STRUCTURE , /V 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.IEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM _ (ff—Iy
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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S $IGNATURE571NITIALS
GARDEN WALL FINAL