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5400 (RR)Building Address Owner Tityl 4 4 Qm&Z P.O. BOX 1504 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 Mailing I Address City I Zip JTel. Contractor Address City jZip ITel. State Lic.City I & Classif. Lic. # Arch., Engr., Designer Address 1 Tel. City Zip State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70DO) of Division 3 of the Business and Prolossions Code, and my license is in full force and effect. SIGNATURE npTr OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for she following reason: (Sec. 7031.5,Busrress and Profes6ous Code: Arty city Or oounly which regokr a permit fo Construct, after, imprOve, dem ksh, or repair any St=ldro, pdof to its issuance aka requfreS fire applicant for Such penr07 to file a signed statement khat he is bcensed pursuant to the provisions of fhe Canfracfor's tkense Law, Chapter 9 (cammenang wan Section 7000) at DrOsmn 3 of the Business and Profesviars Cade, or Nalhe is exempf rhorefrum, and fhe basis NF the afted 8xe1r &ML Any w4aflon of Section 7031.5 by any apprrcaaf for a permit sufijecta the apP6canf to a GWpenatfy of riot nwu Nan five hundred dollars rS500). LJ I, as owner of the property, or my employees wllh wages as their sole Compensation, wlD do the work, and the siruclure is not intended or offered for sale. (See. 7044, BaLmess and Professipns Cade. The Comb -War's license Law duos not apply to an owner of property who buHds or inpraves (hereon and who does such work hfmseff or ffimugh his own employees, provided Mar such improvements aro nal Intended or Offered far sale, if, however. the building or lmprovemenl is sold wdhjn one year at completion. fha owner -budder will have Ire buedoa or 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 Pmfsssions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a confracfor(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. C Mpany ❑ Copy is filed with the city. ❑ Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need nor be completed it the permit is for one hundred dollars ($700) valuation or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ anyperson in any manner so as to become subject to the Workers' Compensation Laws of Calr oidia. Date—Owner NOTICE TO APPLICANT: 9, after maft Ods Cerf teate of EXROnpilon you should become subject to the Workers' Com4xe rffim proWsbns of fhe Labor Code, you must forthwith comply with such provsions or thispermi! 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 Addr 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 Certity that l 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 sof this city to enter the above mentioned property for Inspection purposes. Signature of applicant _ Date _ Mailing Address City, State, Zip BUILDING: TYPE CONST A.P. Number Legai Description Project Description Sq. Ft. Size No. Stories OCC. GRP. No. Dw. Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ ILstlmated 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 Issued by:— Validated by: Validation: INSPECTOR Date Perm CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES $ UNITS 1ST FL. SQ. FT. ® YARD SPKLR SYSTEM 2ND FL. SQ. FT. MOBILEHOME SVC. BAR SINK POR. SO. FT. POWER OUTLET ROOF DRAINS GAR. SQ. FT. ® DRAINAGE PIPING CARP. SQ. FT. DRINKING FOUNTAIN WALL SQ. FT. URINAL SQ. FT. $ WATER PIPING ESTIMATED CONSTRUCTION VALUATION 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. a 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 ® V4c HOUSE SEWER GAS PIPING PERMIT FEE I PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE SETBACK SLAB GRADE FORMS FOUND. REINF. REINF. STEEL GROUT BOND BEAM LUMBER GR. FRAMING ylOOFING� VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING SPECTIONf CERT. OCC. FENCE FINAL GARDEN WALL FINAL PLUMBING GROUND PLUMBING ROUGH PLUMB. SEWER OR SEPTIC TANK GAS (ROUGH) GAS (FINAL) WATER HEATER WATER SYSTEM INSP. SIGNA ELECTRICAL UNDERGROUND BONDING ROUGH WIRING METER LOOP TEMP.POLE SERVICE HEATING & AIR COND. A.C. UNIT HEATING (ROUGH) DUCT WORK HEATING (FINAL) FINAL INSP GRADING FINAL INSP. cu. yd. $ plus x$ REMARKS: SOLAR COLL. AREA STORAGE TANK ROCK STORAGE OTHER APP.IEQUIP.