10964 (PAT)A, 4
P.O. BOX 1504 No, 10964
Building w 78105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Owner
y
Mailing
BUILDING: TYPE CONST. OCC. GRP.
Address L3 il' '
'y- Zip Tel.
Contractor _
Address
City lZip
State Lic. I City
& Classif. !I Lic. #
Arch., Engr..
Designer
Address Tel.
City Zip I State
I J 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
SIf�NAT�FF DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Urense Law For the following
Teason: (Sec. 7031.5,9usiaess and Protessions Coda- Any city or County which requires o
permit to consfrucf, after, improve, dernofth, or repair any structure, prior to its *stuanCe also
requires the applicant for such permit to file a signed slafament that he is Ikensed putsuant to
the provisions of the Contractor's License Law, chapter 9 (commencing with Section 700m) of
Omsion 3 of the Susinass and Professions Code, at that. he is exempt therefrom, and the basis
hu the alleged exemption. Any miption of Sec&,n 703 T. s by any appfkant rot a permR
sutNecfs the applicant 10 a ciW penalty at not mere fhan five hundred dollars ($500).
�] I, as owner of the property, or my employees with wages as their sale compensation, will
faro the work, .and the structure Is not Intended or offered for sale. tSec. 7044, Sulwass attar
Professions Cade: The Conhacfar's License Law does not appfy to an owner of property who
bftfkis or improves thereon and who does such work himself or through his awn employees,
provided that such improvements are not infended or offered far solo, if, however, the buminq
or Improvarriant is sold wilhln one year of conwloWn, the owner-bulder wm have the 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 Professions 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)
❑ 1 am exempt under Sec. B. & P.C. for this reason —
Date 1 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 certify that in the performance of the 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: N. after making fhe; Certificate of Exemption you should become
subject to the Workers' Campensatton provisions of the Labor Code, you must forthwith
comply with such provisions or this permit 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 cartlly that 1 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=
mentloned property for inspection purposes.
Signature of applicant_ Date
A.P. Number
Legal Description
Project Description
J f�i-�aYT ._In
Sq. Ft. No. No. Dw.
Size L 2 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
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:
Mailing Address
City, State, Zip
CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES
1ST FL.
SO FT ® $ UNITS
YARD SPKLR SYSTEM
2ND FL. SO. FT.
MOBILEHOME SVC. BAR SINK
POR. SQ. FT.
POWER OUTLET ROOF DRAINS
GAR. SQ. FT.
DRAINAGE PIPING
CAR P. SQ. FT.
DRINKING FOUNTAIN
WALL SO. FT.
URINAL
SQ. FT.
ESTIMATED CONSTRUCTION VALUATION $ WATEPIPING R
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 LAUNDRY TRAY
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. SO. FT. ® c BATH TUB
SO. FT. @ c WATER HEATER
MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID ® 11/4 c SEWAGE DISPOSAL
SQ.FT.GAR ® V4c HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMrFEE PERMIT FEE
DBL TOTAL FEES MICRO FEE MECH.FEE EFET. FEEELECT. FEE SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK GROUND PLUMBING I 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./EQUIP.
REINF. STEEL GAS (FINAL) TEMP. POLE
GROUT WATER HEATER SERVICE FINAL INSP.
BOND BEAM WATER SYSTEM GRADING
LUMBER GR. FINAL INSP. cu. yd.
FRAMING FINAL INSP. $ plus x$ =$
REMARKS:
ROOFING
VENTILATION
FIRE ZONE ROOFING
FIREPLACE i
SPARK ARRESTOR
GAR. FIREWALL /9 V
LATHING��
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL INSPECTOR'SSIGNATURESIiNITIAL
GARDEN WALL FINAL