12719 (CP)4
P.O. BOX 1504
.L r'.) i.J_`r 1 ','<' 78-105 CALLE ESTADO
Building
Addtass LA QUINTA, CALIFORNIA 92253
Owner ..: F.' i_:.... [;;= ':_ - .' a.r
mafung
Address
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Cit� 1 -
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Contractor
Addr�s�. _,
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State Lic.
& Classif.
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City
Lic. #
Arch., Engr.,
Designer
Address
Tel.
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provlsions of Chapter 9 (commencing with Section
7pp0) of Division 3 of the Business and Professions Code, and my license is in full force and
to fect.
t31un uta ogre
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, 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 live hundred dollars ($500).
❑ I, as owner of the property, or my empti*."l with wages as their sole compensation, will
do the work, and the structure is not inter4ded 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 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 thereon, and who contracts for
such projects with a contractors) 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 self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ 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 thg 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
maws or California. .
Date Owner
NOTWE TO APPLICANT: If, alter melting this Cerlykafe of Exemption you should become
subject to the Workers' Competlsafion pruvislans of the Labor Code, you murl fotfhwfih
comply with such provisions or this Pamull shall be [teemed revakad.
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 abon+3 information is correct.
1 agreeto comply with all clty.and County ordinances and state laws relating to building
construction, and hereby authorlxe representatives sof this city to enter the above,
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address _
City, State, Zip
No. 12719
BUILDING: TYPE CONST. OCC. GRP.
R.P. Number
Legal Description
Project Description
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. 1.
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 Lina - -+
FINAL DATE INSPECTOR J
Issued by: Date....�Pdrmit.
Validated by: Y 4 Z
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL SQ. FT. ® $
2ND FL. SQ. FT.
FOR. SQ. FT. ®
GAR. SQ. FT ®
CAR P. SQ. FT. 0
WALL SQ. FT ®
SQ. FT.
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
BAR SINK
SEWER OR SEPTIC TANK
ROOF DRAINS
DUCT WORK
DRAINAGE PIPING
FOUND. REINF_
DRINKING FOUNTAIN
METER LOOP
URINAL
OTHER APP.IEQUIP.
WATER PIPING
NOTE: Not to be used as property tax valuation
TEMP. POLE
FLOOR DRAIN
MECHANICAL FEES
WATER HEATER
SERVICE
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WATER SYSTEM
WASHER(AUTO)(DISH)
APPLIANCE DRYER
_$
LUMBER GR,
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FRAMING
i
L INSP. (/
LAUNDRYTRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
FIREPLACE
SHOWER
BOILER B.T.U.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
GAR. FIREWALL
WATER HEATER
MAX. HEATER OUIPUI, B.T.U.
SQ. FT. RESID to 11/. c
SEWAGL DISPOSAL
SQ.FT.GAR ® 3/ac
MESH
HOUSE SEWER
INSULATION/SOUND
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE
ELECT FEE
SMI FEE TPLUMB. 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
i
L 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 SIGfJATURESIINlTIALS
GARDEN WALL FINAL 71