9877 (BLCK)4
P.D. BOX 1504 No. Y V T
Building �:_ �3� :"> ;I. 7&105 CALLE ESTADOj
Address LA QUINTA, CALIFORNIA 92253
Owner
Mailing BUILDING: TYPE CONST. OCC. GRP.
Address 3 f
A.P. Number
City Zip Tel.
;; G 4— 4 3 3 2 Legal Description
Contractor
Address
City IZip Fel.-
State Lic. City
& Classif. 4 F 7 5 6, Lic. # � r'
Arch., Engr.,
Designer
Address Tel.
CityI Lic
Zip I State
. #
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, 9hd my license is in full force and
effect.
51GNATunE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, atter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penally of not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvamenfs are not intended or offered for sale. If, however, the buadrng
or improvement is sold within one year of compfstion, the owner -balder 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 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 sal4nsure, or a certificate of
Worker's Compensation Insurance, or a certified ctipy.thereof. (Sec_ 3ao0, Label
Policy No. _ Company _
C] Copy is filed with the city. ❑ Certified co6y 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 thg work for which this permit is issued, I shall not
employ any pperson in any manner so as to become subject to the Workers' Compensation
Laws of Califarnla.
Date -Owner
NOTICE TO APPLICANT: N, a$9r making this Certificate of Exemption 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 this appHcation and state that the above information !s correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby aulhorlxe representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
Project Description
Sit. No.Stories
No. s
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. SQ. FT. ®
WALL SQ. FT. ®
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
A.C. UNIT
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
L`
BAR SINK
BONDING
ROOF DRAINS
I STORAGE TANK
DRAINAGE PIPING
DRINKING FOUNTAIN
SEWER OR SEPTIC TANK
URINAL
DUCT WORK
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
HEATING (FINAL)
OTHER APPJEQUIP.
WATER SOFTENER
VENTSYSTEM FAN EVAP.COOL HOOD
SIGN
GAS (FINAL)
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GROUT
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
WATER HEATER
SERVICE
LAUNDRY TRAY
AIR HANDLING UNIT CFM
BOND BEAM
j
l
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
GRADING
cu. yd.
$ plus x$
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
FINAL INSP.
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
ROOFING
SHOWER
BOILER B.T.U.
SQ. FT. ® c
BATH TUB
REMARKS:
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/Ic
FIREPLACE
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
GAR. FIREWALL
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE INST.
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
L`
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
I STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
j
l
G
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
INSPECTOR'S SIGNkTURES+INITIALS
GARDEN WALL FINAL