05306 (BLCK)Building
Address :ZcLnPIKYJAt;
Owner
Address P 0. BOX
155.5
City Zip Tel.
L�i "NINTik J1
Contractor
Address
City lZip
State Lic. City.
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
City Zip State
Lic. #
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.
f ,NA RL _ Qp^'
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the ConlractoYs License Law for the fallowing
reason: {Sec. 7031-S.9usmess and Professions Code: Any city or county which requires a
pennr7 to construct. affer. fmprove, demah'sh, or repair any structure. prior to its Issuance afso
requires the appscant for such permit to NO a signed statement that he is lrconsad pursuant to
Me provisions of the Contractor's license taw. Chapter 9 (camw* Oil with Section 7000) or
Divisiom 3 or fho &rsiness and Pmfessi ms Code, or Mal he is exempt Ihorarrom, and fho basis
for rho alleged exemodom Any vaalation of Soclkrn 7031.5 by any appkcant for a permit
suh)ecfs the appbi l to a civil penalty of not mare thorn live hundred dollars (S500),
LJ I, as owner of the property, or my employees with wages as their sole compensation, will
do the wo(k, and the structure is not intended or offered for sale. [Sec. 7044, 8uisness and
Proresamns Code. The Caafracmrs License Law does not apply to an owner of properly who
buWs or improves thereon and who does such work himself or through his own employees,
provided that such kviovemonis amnot Infended or offered far safe. n, however, rho building
Or improvement is sold Wllhfn one year of cumpiefkrn, the ownar-budder wd7 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 dnd Professivns 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.)
❑ I am exempt under Sec.—B. & P.C. for this reason —
Date_ , I I , Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, ore cadiffcate of
Worker's Compensation Insurance, ora certified copy thereof. (Sec. 3800, Labpr.C.ode.)
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 (S100) 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 Cal ffornia
Date ` - Owner
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption you should become
sulyect 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 information Is correct
1 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. 05306
BUILDING: TYPE CONST. OCC. GRP.
P. Number
Legal Description ' 4 Fr ir;. OF' 6-600I' 107%' BLOCK Wet
Descripti
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
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
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
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE,TEMIPERM
LAVATORY
HEATING SYSTEM FORCFD rRAVITY
BOILER B.T.U.
AMPERES SERV ENT
SHOWER
BATH TUB
SQ. FT. ® c
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B_T_U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® Vic
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 APP./EQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
LUMBER GR.
FRAMING
WATER SYSTEM
GRADING
cu. yd.
$ plus. x$
=$
FINAL INSP.
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
M ESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT_ OCC.
FCwlnc rw�
SIGNATURESIINmAL,S
GARDEN WALL FINAL