9813 (PAT)T4ht
��
rJ 3 b� P.O. BOX 1504 No
Building ? ?r� -1 , 78-105 CALLE ESTADO
Address `- LA QUINTA, CALIFORNIA 92253 7"
Owner
MAng BUILDING: TYPE CONST. OCC. GRP
Address ,
A.P. Number
City_'._ Zip -1 2 t_ Tel.
%f1A"``__ '3 Legal Description
Contractor
,-
Address
City ]Zip I Tel.
State Lie. City
& Classif. Lie. #
Arch., Engr.,
Designer
Address Tel.
City Zip State
Lie. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
t
7t100J of Division 3 of the Business and Professianc Code, and my license is in full force and
effec.
SIGNAIlIRE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the foltowing
reason: (Sec. 703a.5,8uskrvss and Professions Code: Any city or county which requires a
par nif to constrircf, alter. Improve. demoNsh, or repair any structure, prior to ds Issuance also
requires the appkant for such permr7 Ie Me a stgned statement that he is Ncenaed pursuant to
the provisions of the Cantreclor's License Law, Chapter 9 (commencing wilh Section 7000) of
DfWsion 3 of the Business and Professions Cade, or that. he is exsYttpf therefrom, and rhe basis
for the alleged exempfion. Any violation of Section 7031.5 by any applicant for a permit
subjects She appfrcanf to a civil penalty of not more than five hundred dollars (5500).
111, as owner of the property, or my employees with wages as their sale compensation, will
do the work, and the structure Is not Intended or offered for sale. (3ec. 7044, 8uisness and
Professions Coda= The Canfractor's license Law does nor apply to an owner of properly who
txdids or Improves thereon and who rales such work h[rnsalr or through his own employees,
provided that such improvements are not Intended or offered for sake. 11, howev&r, the buil dfng
or Improvement is said within one year of corWelfon. the ovmer•bultder WN 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 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 thV work for which this permit is issued, I shall nor
employ any person in any manner so as to .become subject to the Workers' Compensation
Laws of California. -
Date Owner
NOTICE TO APPLICANT: ffj after makft this CArtillcatis of ExampUon you should become
subject to the Workers' Compensation 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 certify that I have read Ibis 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 -
me nlioned property for Inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
9813
Project Description
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
>; .
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. ®
CAR P. I SQ. FT. ®
WALL SQ. FT. ®
SO. FT.
ESTIMATED CONSTRUCTION VALUATION $
UNITS
SLAB GRADE
ROUGH PLUMB.
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
ROUGH WIRING
DRAINAGE PIPING
ROCKSTORAGE
DRINKING FOUNTAIN
GAS (ROUGH)
URINAL
HEATING (FINAL)
WATER PIPING
NOTE: Not to be used as property tax valuation
GAS (FINAL)
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DI S H)
APPLIANCE DRYER
BOND BEAM
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
GRADING
cu. yd.
$ p1Us xE
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. 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 ® 3Ac
HOUSE SEWER
FIREPLACE
GAS PIPING
PFRMIT FFF
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
ROCKSTORAGE
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.
$ p1Us xE
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
y� �
`-� 'I" "
I
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATUR>±SIINITIALS
GARDEN WALL FINAL