15821 (PAT)r
Building
Address 54-711 Herrera
---.._. ]may:; L. hayward
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Mailing
Address Sd_;,C- i=5 abO- e
City La Q1Jtintca Zlp 9?253 1 Tel. 504-
Ow,- er Builder
Address
ity Izip I Tel.
State Lic. City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City I Zip I State I
Lic. #
1 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.
5[ GHA7JJF 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
1 permit fo construct, after, 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
14 the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
IlffyVV Division 3 of the Business and Professions Code, or that he is exempt therefrom, and the basis
for the alleged exemption. Any vlotafion of Ssction 7031.5 by any applicant for a permit
subjects the a0plicant to a civil penally of not more than five hundred dollars ($500).
❑ I, as owner of the prop", 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 CL-_Jo. The Contractor's Oconse Law does not apply to an owner of property who
builds or rmprrre:= thereon and who does such work himself or fhrough 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 knprove for the purpose of sale )
O 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
t
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. ❑ Cerlificd 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 toss.)
1 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
Iawsof'CaIl ernla_
Pate -Owner
NOTICE TO APPLICANT- It, after making Ihm 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 pemik shall be deemed revoked
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($1D0,000), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
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 appticatidn and state that the above information Is cdrrscL
I agree to comply with all city and county ordinances and state laws relating to building
construcll4n, and hereby authorize representatives of this city to enter the above•
mentioned property for Inspeclion purposes.
Signature of applicant Data
Mailing Address
City, State, Zip
No. 15821
BUILDING: TYPE CONST. OCC. GRP.
A.P_ Number
Legal Description
Project Description Lattice Yat4-La
Sq. Ft.
Size c�,�t%
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
delL)()a Q()
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
; 5
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: late Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO.
ELECTRICAL FEES
NO.
PLUMBINV FEES
1ST FL SQ. FT. ®
2ND FL. SO. FT w
POR SQ.FT 0
GAR. SQ. FT. ®
CAR P. SQ. FT ®
WALL SQ. FT. @
SQ. FT. @
ESTIMATED CONSTRUCTION VALUATION
$
UNITS
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
$
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(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.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ FT.GAR ® 3/ic
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE
PL.CK. FEE
I 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
xS =$
LUMBER GR.
FINAL INSP
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
/
L
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
I NSULATI ONISOU N D
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSP ECTOR'S SIGNATURES11N171AES
GARDEN WALL FINAL
94
1