04602 (BLCK)J 4 4 "
Building P.O. BOX 1504
: _, c ,_,<,,,' ., :• 78-105 CALLE ESTADO
Address
- LA QUINTA, CALIFORNIA 92253
Owner
Vallev
Mailing
Address
City Zip
Contractor
Address
ity ZIP Tel.
State Lic. t City
& Classif. Lic. #
Arch., Engr„
Designer
Address Tel.
City Zip [State
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provislons of Chapter 9 (commencing with Section
700p) of Division 3 of the Business and Professions Code, and my license is in full Force and
effect.
GNA7
QA7E
OWNER -BUILDER DECLARATION
I hereby affirm that I Am exempt from the Contractor's License Law for the Following
reason: (sec. 7031.5,ausrhes5 and Froressions Code: Any City or comfy which requires A
pefmit to Consfruci, Eller, lmPove, demolish, Of repalr Any structure, prior to its Issuance also
rspukes the apphConr for such permil to ria a signed stalement [har he is ibcensad pursuant to
6he provlskxrs of the Con[racfar's ticense Law, Chapter 9 (Commencing with section 7000) of
Division 3 of the Business and Professions Code, or that he 1s exempt therefrom, and the pasts
for the alleged exemplmm Any violation of Section 7031,5 by any �vpRcanf far a perms
subjects the app,NCanf to a Cfvll penalty cl not more than five hundred dollars fS 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 far sale, fSec. 7044 aursness and
Professions Coda: The Contractor's License Law doss not apply to an owner of property who
builds or knproves thereon and who roes such work himself or through his own employees,
provided that such Improvements are not intendad or offered far sale- 11.r wra have the burden
however, the bugdalp
or Improvement is sold within one year of Complefkn, the owner�[rilde of proving that he did not build or deprave far the purpose of safe,)
:7 I, as owner of the property, am Exclusively contracting with licensed contractors to con-
struct the protect. (Sec - 7044. Business and Professiohs Code: The Canimctar's Lkense Law
does not apply to an owner of Property who burlds or improves thereon, and who contracts for
such projects with a confraclorfs) licensed pursuant to the Contractors License Law.)
❑ 1 am exempt under SeC.�� & P•C for IhIS reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a Certificate 01 consent to self -insure, or a certificate of
Warkar's Compensation Insurance, Ora 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 11 the permy
less.)
is for one hundred dollars ($100) valuation
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.
Dale Owner
NOTICE TO APPLICANT: d, alter maMng Phis Certifrca[e of Exemplran you should become
subject to the Workers' Compensation provisions of fha Labor Code, you must forthwith
Comply with such provisions of 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, (Sac. 3097, 00 Code,)
Lender's Name
Lender's Address — —
This Is a bullding permit when properly filled out, signed and validated, and is subject to
axpirat[on 1f work thereunder Is suspended for 180 days -
I certify that I have read this application and state that the above information is correct.
I agree to Comply with all City and county ofdinences and state laws relating tto building
construction, and hereby authorize representatives of this city 10 enter the above-
men]lOned property for Inspection purposes,
Signature of applicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE CONST.�OCC. GRP.
A.P. Number 7 ; 4
Legal Description
Project Description
Sp, Ft.
Size Stories No. Dw.
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.Perm
Validated bv:
Validation:
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOL09NO90 - ASSESSOR'S OFFICE, HARD COPY -FILE
NO
PLUMBING FEES
NO ELECTRICAL FEES
CONSTRUCTION ESTIMATE
s
UNITS
YARD SPKLR SYSTEM
tST FL SO Fl rp
BAR SINK
2ND FL SO FTT
MOBILEHOME SVC
ROOF DRAINS
POR So FT &
POWER OUTLET
DRAINAGE PIPING
SO FT (t
GAR
DRINKING FOUNTAIN
CARP SO FT 6
SO FT 0URINAL
WALL
WATER PIPING
SO FT 0
ESTIMATED CONSTRUCTION VALUATION
S
FLOOR DRAIN
NOTE Not to Ue used as property tax valuation
WATER SOFTENER
MECHANICAL FEES
WASH ER(AUTOXDISH)
SIGN
VENT SYSTEM FAN EVAP.COOL
HOOD
GARBAGE DISPOSAL
APPLIANCE DRYER
LAUNDRYTRAY
FURNACE UNIT WALL FLOOR
SUSPENDED
KITCHEN SINK
AIR HANDLING UNIT
CFM
TEMP USE PERMIT SVC
WATER CLOSET
ABSORPTION SYSTEM
B.T.0
POLE, TEMIPERM
LAVATORY
COMPRESSOR HP
AMPERES SERV ENT
SHOWER
HEATING SYSTEM FORCED GRAVITY
SO FT ® c
BATH TUB
B T U.
WATER HEATER
BOILER
SO FT @ c
SEWAGE DISPOSAL
SO. FT. RESID (9 1 V. c
MAX HEATER OUTPUT, B T U
SO FT.GAR rg �.c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
SMI FEE PLUMB FEE
PERMIT FEE
MECH.FEE
bL.CK FEE CONST FEE ELECT.FEE
F—LDBL TOTAL FEES
MICRO FEE
HEATING 8 AIR GOND SOLAR
PLUMBING
ELECTRICAL
STRUCTURE
COLL AREA
UNDERGROUND
A.0 UNIT
SETBACK
GROUND PLUMBING
HEATING (ROUGH)
STORAGE TANK
ROUGH PLUMB
BONDING
SLAB GRADE
DUCT WORK
ROCK STORAGE
SEWER OH SEPTIC TANK
ROUGH WIRING
FORMS
HEATING (FINAL)
OTHER APP.IEOUIP
GAS (ROUGH)
METER LOOP
FOUND REINF
'
GAS (FINAL)
TEMP POLE
EINF STEEL
R_
FINAL INSP
•
WATER HEATER
SERVICE
GROUT
WATER SYSTEM
GRADING
BOND BEAM
cu yd.
FINAL INSP
LUMBER GR
=$
$—Plus-4
FINAL INSP
FRAMING
REMARKS;
ROOFING
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
r G
L FI AL INSPECTION " l � � Q
VV
CERT OCC
FENCE FINAL
INSPECTQR'5 SIGI'IATURESIINITlALS
c Oncni 1MAI L FINAL