11167 (PAT)-Ctl9p at AF (KUWCJJ
Building _7 _ L- - ;f, l ,•,� rf -'r
Address: -
Owner
Mailing
Address
City Zip Tel.
a. c r, ?
Ate::: .: .. .
Contractor
Address
City lZip ITO:
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
city Zip I 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.
51GNATunE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sea 7031.5,Business and Professions Coda: Any CRY or county which requires a
permif fo constmct, after, Improve, demolish, or repair any strucfura, prior to its ilsvitance also
requires fire applicant for such pemlll to file a signed statement that he Is Ik ensed pursuant to
tiro Provisions of the Contractor's License Law, Chapter g {commencing with Section 7000) of
LNrlsion 3 of the Business and Professions Code, or that he is exompl therefrom, and fha basis
for the afted examptkm. Any violadon of Section 7031.E by 'any applicarn for a permit
subyects the applicant to a cW penalty of not more than five hundred db8ars (S5t10)-
`eN as owner of the property, or my employees with wages as their sole compensation, wlII
d; {he work, and the structure is not intended or offered for sale- [Sec. 7044, Bussness and
Prolessiorrs Code- The Contractor's license Law does not apply to an owner of property who
builds or Improves Iheno and who does such Hark himself or through his own employees,
Provided that such kwtovemenis are not intended or offered for sale. If, however, the budding
or improvemenl Is sold wifhin one year of completion, the owner -builder w1ll have rho, burden
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-
.struct the project. (Sec. 7044, Business and Proles wons 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) 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 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.
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 cartiry that In the performance of the work for which this permit is issued, I shall not
employ any ppeBrson in any manner so as to become subject to the Workers' Compensation
Laws of Cali omia.
Date Owner
NOTICE TO APPLICANT: If, after maklhg ffils CerWcafe of Exemption you should become
subject to the Workers' Compensation provfsiens of the Labor Code, you must forthwith
comply with such provisions ar this pemrN shall 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 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 of this City to enter the above
rrentloned properly for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
BUILDING: TYPECONST
A.P. Number
Legal Description
Project Description
E
OCC. GRP
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL c
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
INSPECTOR
Issued by:
Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO.
ELECTRICAL FEES
NO.
PLUMBING FEES
1ST FL. SQ. FT. ®
2ND FL. SQ. FT.
POR. SQ. FT.
GAR. SQ. FT. @
CARP. SO. FT. ®
WALL SQ. FT.
SO. FT.
ESTIMATED CONSTRUCTION VALUATION
$
UNITS
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
I
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
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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.
SQ. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11A c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
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
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
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_ $
LUMBER GR.
FINAL INSP.
FRMING l `I
A
{NSP.
[+�
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SKIN ATURESlINITIALS
GARDEN WALL FINAL