9996 (BLCK)Building
Address
Owner
Mailing
Address
City
P.O. BOX 1504 . No. 9996
78-105 CALLE ESTADO
LA ❑UINTA, CALIFORNIA 92253
BUILDING: TYPE CONST. OCC. GRP.
P. Q. Box 36G A.P. Number
Zip lTel.
La Quintal ' 253
Contractor
_ai1-_">-n ;° ssonry
Address
0. Bo
State Lic.Cit
r . it t 1 r, y
J
&Classif. 16;i4 Lic.# J.63ry
Arch., Engr.,
Designer -
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereb atlirm that I am licensed under provisighs of Chapter 9 (commencing with Section
700p) of �ivislon 3 of the Business and Professions Code, and my license is in Iuli force and
effect.
31GH9Ti1RE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors Lk:ense Law for the following
reason, (Sec_ 7031.5,Business and Professions Cade: Any city or county which requires a
permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit [a Tile a signed stelemeof fiat he Is licensed pursuanl to
11713 provisions of the Contractors license Law, Chapter 9 tcammencing wlfh Section 70001 of
Vw,-Jon 3 of the Business and Professions Code, or thathe is exempt therefrom, and the basis
for the alleged exemption. Any violation of Seclion 7031.5 by any applicant for a permit
subjects iia eppkpant to a civil penalty of not more than five hundred doAWs f$500) -
r7 I, as owner of the property, or my em pioyees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sate. fSoc. 7044. Buisnass and
Wasslons Code: The Contractor's License Law does not apply to an owner of property who
buRI5 or Improves thereon and who does such work himself or ihroagh his own employees,
provided that such Improvernenls are not Wended or offered for sato. If, however, the budding
or improvement is sold wilfrin one seer of Compl$tipn, the owner-bulider will have the burden
of proving that he didnot build or improve for the purpose of sate.)
❑ 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 confractor(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
11 Copy is Illed with the city. 17 Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the pemrlt 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 person in any manner so as to become subject to the Workers' Compensation
Laws of California -
Date Owner
NOTICE TO APPLICANT. if, after making this Certificate of t:xemptien you should become
subject to the Workers' Compensation provlskms of the Labor Code, you must forthwith
comply with such provisions or Ibis perm!t 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 Nam
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiratian if work thereunder is suspended for 160 days.
E certify that i have rand this application and state that Vie above infonnalibn is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives sol this city to enter the above-
mentioned property for Inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
Legal Description_
Project Description
T Ci 11
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 FEEE-
1ST FL. SQ. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCT WORK
ROCK STORAGE
FOUND. REINF.
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT.
HEATING (FINAL)
OTHER APP.IEQUIP.
REINF. STEEL
DRAINAGE PIPING
CAR P. SO. FT. ®
WALL SQ. FT. ®
DRINKING FOUNTAIN
SERVICE
FINAL INSP.
URINAL
SQ FT ®
�(
WATER SYSTEM
ESTIMATED CONSTRUCTION VALUATION Is
GRADING
cu. yd.
$ plus x$
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
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.
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 ® 3/4c
HOUSE SEWER
INSULATION/SOUND
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PLCK.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 lY
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIG NATURESIINITIALS
GARDEN WALL FINAL