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07891 (PLBG).. 4_ T4t�t 4 4 Q" P.O. BOX 1504 Building 5�4-ZOO Col`tez Address Owner Mailing Address 43=87 R z -: _ n , City I Zip ITel. Haag Construction. Sir Address City lZip I Tel. No. 91. 10-105 CALLE COADO 1, LA QUINTA, CALIFORNIA 92253 -• State & Classif. 410275 I Lic. # 1138 Arch., Engr., Designer Address Tel. City Zip I State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby afip'rm that lam lice��d er 9 (commencing with Section 71,00) of DlvVon 3 of �i3 Imy license is In,f i II force and r effect. w: r _ I AT 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 Seclion 7000) of lXvislon 3 of the Business and Professions Code, or that he is exempt theretiorn, 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 five hundred dollars ($500). ❑ I, as owner of the property, 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, Bussness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves (hereon and who does such work himself or through his own employees, provided that such improvu"nis are not intended or offered for sale. If, however, the twildtng or improvement is sold wilhA one year of cvmWation, the owner -builder will have the burden 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- 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.) ❑ I 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 Laws of California. Date Owner NOTICE TO APPLICANT: It, after making this 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 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 appllcaflon and state that the above information is correct - agree to comply with all city and county ordinances and state laws relating to bullding 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 BUILDING: TYPE CONST. OCC. GRP A.P. Number r74-192-011 Legal Description Lot 13 h 14 a Project Description Sewer to house 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.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 5/1WOermit Validated Vali 'R CONSTRUCTION ESTIMATE �a NO. ELECTRICAL FEES NO. PLUMBING FEES f SQ. FT. $ UNITS ® SQ. FT. YARD SPKLR SYSTEM ® FT. MOBILEHOME SVC. BAR SINK _ SQ. 0. SQ. FT. POWER OUTLET ROOF DRAINS SQ. FT. DRAINAGE PIPING SO. FT. DRINKING FOUNTAIN SQ. FT. URINAL ;dNSTRUCTiON VALUATION $ WATER PIPING de used as property tax valuation FLOOR DRAIN MECHANICAL FEES WATER SOFTENER FAN EVAP.COOL HOOD SIGN WASHER(AUTQ)(DISH) DRYER GARBAGE DISPOSAL I"T WALL FLOOR SUSPENDED LAUNDRY TRAY LJNIT CFM KITCHEN SINK (STEM B.T.U. TEMP USE PERMIT SVC WATER CLOSET' HP POLE,TEM/PERM LAVATORY :M FORCED GRAVITY AMPERES SERV ENT SHOWER B.T.U. SO. FT. ® c BATH TUB SQ. FT. ® c WATER HEATER IUTPUT, B.T.U. SQ. FT. RESID ® 11/4 c SEWAGE DISPOSAL SQ.FT.GAR ® 3/4c HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE TOTAL FEES --[---MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE S-rF±UCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR GROUND PLUMBING UNDERGROUND A.C. UNIT COLL. AREA r ' 4pE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK ROUGH WIRING DUCT WORK ROCK STORAGE ;EINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEQUIP. rEEL GAS (FINAL) TEMP. POLE WATER HEATER SERVICE FINAL INSP. AM GR• WATER SYSTEM $ GRADING cu. yd. plus x$ =$ FINAL INSP. 3 FINAL INSP. 3 TION NE ROOFING CiF gRRESTOR REMARKS: REWALL 3 plOWSOUND GRADING NVECTION ACC. FINAL INSPECTOR'S SIGNATURESRN1TIALS N WALL FINAL