10679 (PLBG)4
P.O. BOX 1504 No. 10679
Building
Address :, �- LA QUINTA CAL CALIFORNIA 92253
-
Owner
Mailing BUILDING: TYPE CONST. OCC. GRP.
Address :FSI} I . ';- u
A.P. Number
City Zip Tel
2 6 5�, r ' I Legal Description
Contractor
_. }_, _ Project Description
Address
City Zip Tel.'
ry•, A�;
State Lic. City
& Classif. Lic. # 6) n Sq. Ft. No. No. Dw.
Arch., Engr., Size Stories Units
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel,
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I herehy affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Dlvislon 3 -df the Business and Professions Code, and my license is in full force and
effect.
Sf£ NA r0 RE - DATE
OWNER -BUILDER DECLARATION Estimated Valuation
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Buslness and Proresatens Code.- Any cRy or county which requires a
permit to construct, alter, Improve, demolish, or repair any structure, prior to ks Issuance also
rewires the appricant for such permit to Tela a signed statement that he is kansod pursuant to PERMIT AMOUNT
the provislohs of the Contrac(or's License Law, Chapter 9 fcommencing wtlh Sectlon 7DOD) of
Division 3 of the Business and Prolessians Cade, or that. he is exampt marorrom, and the basis
for rhe alleged exempffom Any wotalion of Section 7091.5 by any applicant for a perms Plan Chk. Dep_
subjacts the applicant to a civil ponally of not more then five hundred dofvs (5500).
F1 1, as owner of the property, or my employees with wages as their sale compensation, w7i11 Plan Chk. Bal.
do the work, and the structure Is not Intended or offered for sale. (Sec. 7044, Sumness and Const.Prufesslobs Code: The Comractor's License Law does nor apply to an owner of property who
bWids or Improves thereon and who does such work himself or through his own employees, Mech.
T.—
provided that such improvements are not Intended or offered for sale. It, however, the build.'arg
or Improvement is sold within one yaar al completion, the owner -binder will have tho burden Electrical
of proving that he did not build or improve for the purpose of sale.)
❑ 1, as owner of the property, am exclusively Contracting with licensed contractors to con- Plumbing
struct the project. (Sec. 7044, Business and Processions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for S.M,I,
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
ElI am exempt under Sec. Grading B. & P.C. for this reason —
Driveway Enc.
Date Owner Infrastructure
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:)
PoIICy No.
E'I'Copy is filed with the city. ❑ Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
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
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 Cenilicats of Exemption you should become ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Carlo, you must forthwith
comply with such provisions or Ihis permit shall be deemed revoked. Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) Side Setback from Property Line
Lender's Name
Lender's Address FINAL DATE INSPECTOR
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.
J certify that I have read this application and state that the above information Is correct. Issued by: Date Permit
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-
mentloned property for inspectlon purposes. Validated by:
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO.
ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL.
2ND FL.
POR.
GAR.
CAR P.
WALL
ESTIMATED CONSTRUCTION
SQ. FT. ® $
SO. FT.
SO. FT.
SO. FT.
SO. FT.
SO. FT. @
SO. FT. @
VALUATION $
ROUGH PLUMB.
BONDING
UNITS
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
YARD SPKLR SYSTEM
ROCK STORAGE
FOUND. REINF.
MOBILEHOME SVC.
BAR SINK
HEATING (FINAL)
OTHER APPJEQUIP.
POWER OUTLET
ROOF DRAINS
TEMP. POLE
DRAINAGE PIPING
WATER HEATER
SERVICE
FINAL INSP.
DRINKING FOUNTAIN
BOND BEAM
LUMBER GR.
WATER SYSTEM
URINAL
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
ROOFING
FLOOR DRAIN
MECHANICAL FEES
REMARKS:
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FIRE ZONE ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
SPARK ARRESTOR
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/. c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
HOUSE SEWER
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
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)q:2 , �// ///��ry
`
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
LUMBER GR.
WATER SYSTEM
GRADING
cu. yd.
$ -Plus-X$-=$
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL