002502 (RPL)T4ht 4 4 Q"
P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address —493 RM LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address 7 5-0`5 ;may C hfo
City Zip Tel.
Pair, &':SOLE ?^
Contractor
National
Address
,1W05e
City Zip Tel.
State Lic. City
& Classif. 2130 Lic. #o
Arch., Engr.,
Designer
Address Tel.
City ZipI State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Dlvislon 3 of the Business and Professions Code, and my license is In full force and
effect.
SL,HATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec_ .7037.5,Bus0ass and Professions Coda: Any city or county which requires a
Parma to construct, affer, improve, dsmolish, or repair any structure, prior to Its issuance also
requires the applicant for such permil to file a 51 nod statement that he is licensed pursuanl to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Seclion 7000) of
tlliivvsion 3 of the Business and Professksns Code, or
that he is exeaV Ihofuhum, and the basis
for the alleged exempllon. Any vkNalion of Secrlwl 7031.5 by any applicant for a permit
subjects the appUcanl to a clull penalty of not more than five hundred dollars ($5001•
I, as owner of the property, or my employeea with wages as their sole compensailon, will
do the work, and the structure is not intended or Offered for sale. (Sec. 7044, Buisnsss and
Professions Code: The Camractor's License Law doss not appiy to an owner of property who
bu+7ds or improves thereon and idle does such work himself or through his own amptoyaas,
Provided that such improvemenls are not Intended or dflered for sate. 11, howover, the buliding
or improvement is sold wflho one year of comptetk7n, Ma ownef•bultder will 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 contraclor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 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 NG. Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WO R KERS' 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 thV work for which this permit is issued, I shall not
employ any ppefson in any manner so as to become subject to the Workers' Compensation
Laws of CaIilomia.
Date Owner
NOTICE TO APPLICANT: If after making this Certificate of Erampfion you should become
subject to the Workers' Compensation provisions of the Labor Code, you most 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 certify that I have read this application and state that the above information Is correct.
I agree to comply with all elty and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date.
Mailing Addres
City, State, Zip
HARD COPY
BUILDING: TYPE CONST
A.P. Number
Legal Description_
Project Description
No. _012
OCC. GRP,
P.H.A. `a4M�f a
Sq. Ft.
Size
No. No. Dw.
Stories Units
New 1-1 Add ❑
Alter ❑ Repair ❑ Demolition ❑
.0i reelestal
Estimated Valuation
.., 1.
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 7-20-8tPermit
Validated by:
Validation:
A6071 7 29 225( gib.
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SQ. FT. ®
POWER OUTLET
IROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I SQ. FT. ®
GROUT
WATER HEATER
WALL SQ. FT. ®
FINAL INSP.
DRINKING FOUNTAIN
BOND BEAM
WATER SYSTEM
URINAL
SQ. FT. ®
=$
LUMBER GR.
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
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
VENTILATION
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIRE ZONE ROOFING
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FIREPLACE
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.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
JDBL
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.
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
I NSPECTOR'S SIGMATU RES11INITIALS
GARDEN WALL FINAL