08810 (SOTB)P.O. BOX 1504
Building aiT,r CAME PCA ��Si LLA QUINTA CALIFORNIA 92253
Owner
Mailing
Address p.(). Bo);-
City
0YCity Zip
174 1 4T7 =i7 1 fF.7ti1 ?fin.-.
Contractor
Aaa ress I
City Zip 1 Tel.
AN DIEGO CA 192113 113--2.39-41146
State Lie. City
& Classif. 4664037 Lie. #
Arch., Engr.,
Designer
Address Tel.
City I
Zip _ (State
11 Lie. #
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, and my license is in full force and
effect.
SkGNATi1RE DATE
OWNER -GUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
II reason: (Sec. 7031.5,Business and Professions Code: 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 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 penalty 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 fhereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder 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 fhereon, 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
I
Date Owner _
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Cem i Dance, or a certi�k G jr,*er 3800, Labor Cnda.)
Policy No.is ■ompany 5 �
qt 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 the work for which this permit is issued, I shall not
Lav s of California.y person
n in any manner so as to become subject to the Workers' Compensation
Date Owner
NOTICE TO APPLICANT: If, after 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 application and state that the above informatlon 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-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address _
City, State, Zip
No. 08810
120' TV 'iONEIIR
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number
Legal Description
(Project Description, ♦Q 1201 W TC ILA _
OR � KI"lAJ GAME
Sq. Ft.
Size
No. No. Dw.
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
100 no
TOTAL
:;' On oni
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 try:
Validation:
CONSTRUCTION ESTIMATE
GROUND PLUMBING
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
2ND FL. SQ. FL
FOR. SQ. FT. ®
GAR. SQ. FT. ®
CARP. SQ, FT. ®
WALL SQ. FT.
SQ. FT. @
ESTIMATED CONSTRUCTION VALUATION $
SLAB GRADE
UNITS
BONDING
HEATING (ROUGH)
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
ROCK STORAGE
DRAINAGE PIPING
GAS (ROUGH)
DRINKING FOUNTAIN
HEATING (FINAL)
URINAL
REINF. STEEL
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
SERVICE
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
WATER SYSTEM
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
LUMBER GR.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FINAL INSP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
VENTILATION
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
FIREPLACE
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SQ. FT. ® c
BATH TUB
GAR. FIREWALL
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
INSULATION/SOUND
FINISH GRADING
GAS PIPING
PERMIT FEE
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
ROCK STORAGE
/y
OUND, REINF. 'l
C/
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
INSPECTOR'S SiG NATU RESI I N FT IALS
GARDEN WALL FINAL