003592 (RPL)4 4 Qui4trcv
t
P.O. BOX 1504 o, 003592
Building 78-105 CALLE ESTADO
Addrg LA QUINTA, CALIFORNIA 92253
Owner
Mailing BUILDING: TYPE CONST. OCC. GRP.
Address .{ - A.P. Number 774_.1 L1 a f;C12
City I Zip JTel.
c z :i 4 —
Contractor
ress
City lZip
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City I Zip I State I
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. .
tGNAT{7rIr DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the followtng
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requkes a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
letruiros fha applicant for such permit to Me a signed statement that he is licensed pursuant to
the provisions o► the Contractor's License Law, Chapter 9 (commencing with Soctiwr 7000) of
airfston 3 of the Business and AwessMns 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 penally of not more than five hundred dollars ($500).
R I, as owner of the properly, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sate. (Sec. 7044. Bussness and
Prolessions 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 -budder 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 contractor(s) 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 thq work for which this permit is issued, I shall not
employ arty person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: tr, after making Ws Cortificale of ExempBon you should become
subject to the Workers' Cornpansalion provlsfons of the Labor Code, you must forthwith
comply with such provisions or rhis 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 it work thereunder is suspended for 180 days.
I certify that f have read this application and state that the above informalfan 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 outer the above -
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
Legal Description
Project Description .-�CNA-1
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.
• "r
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:
HARD COPY
CONSTRUCTION ESTIMATE
NO.
ELECTRICAL FEES
NO.
PLUMBING FEES
1ST FL. SQ. FT. ®
2ND FL. S0. FT.
POR. SQ. FT. ®
GAR. SQ_ FT. @
CAR P. SQ. FT. ®
WALL SQ. FT. @
SO. FT. a
ESTIMATED CONSTRUCTION VALUATION
S
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 FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B,I.u.
SQ. FT. 0 c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® lAc
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 S AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWEH OH SEPI IU 1ANK
ROUGH WIRING
DUCT WORK
RUCK 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
WATER SYSTEM
GRADING
du. 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 SIGNATUREVINJTIALS
GARDEN WALL FINAL