09222 (BLCK)Address 79-66T Core Larry
Hen R. Olson, Jr.
Address
City i Zip
i
State Lic.; City
& Classif.i Lic. #
Arch., En6r.,
Designer
Address Tel.
P.O. BOX 1504` Q .
78-105 CALLE ESTADO
LA:QUINTA, CALIFORNIA 92253 X
City I ZipI State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am,licensed under provisions of Chapter 9 (commencing with.Section
7000) t. of Division 3 of the Business and Professlona"Code, and my license is in full force and
effec
SIGNATURE 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
permit to construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance also
requires the ;applloant. for such permit to RM a signed statement that he is licensed pursuant to
the provisions. of the Contractor's License Law; Chapter 9. (commencing with Section 7000) of
Division .3 ofi the Business and; Professions 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 penalty of not more than five hundred'dollars ($500). '
"as•owner of the'property, or.my employees with wages as their: sole compensation; will
M&Ihe work, and the structure is not Intended or offered'foi sale. (Sec. 7044, S&Isness and
. ,Professions Code: The Contractor's License Law does not apply to an owner of property who _
• �bulkis• 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. n however, the building
or Improvement Is sold within one year of completion, the owner -builder wig 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 improve* thereon, and who contracts for
such projectswith 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 1 have a certificate of consent to self -insure; or a certificate of
Worker's Compensation Insurance, ora certified copy thereof. (Sec. 3800,1abor Code.)
Policy No. .Company
O Copy is filed with the city. ❑ Certified copy.is hereby furnished.
I
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.certity that In the perfor nce oft p work for which this permit Is Issued, I shall not
employ any parson in any m n'n s o becom ubJec ' th� Workers
Laws of California. f,
Date ,Owner
NOTICE TO APPLICANT: K _ -making this a ate 'tion. you . become
sub)ect tol the Workers' o nation provisions of the Labor Code, you must forthwith
comply with such provisions or thispemrg 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 subjectto
expiration it work thereunder is:suspended for 180 tys:
I certify that I.haye read this application and state that the above Information is correct.
I agree to comply with all city and county ordinances;and state'laws relating to:bullding
construction, and he 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,
Number 6i7-113—nis _
09222
Legal Description of 75 of Tract 21RO
Project Description 2 24,11 O¢ Go !41 nralr WA 1 1
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. .42
Grading
Driveway Enc.
Infrastructure
TOTAL 81.42
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. ® $
UNITS
COLL. AREA
2ND FL. SQ. FT.
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
ROUGH WIRING
DUCT WORK
DRAINAGE PIPING
CAR P. SQ. FT.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
DRINKING FOUNTAIN.
WALL SQ. FT.
GAS (FINAL)
SO. FT. @
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
CO
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FINAL INSP.
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.T.U.
SQ. FT. @ c
BATH TUB
FIREPLACE
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID @ 1 V c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3yic
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
dGROUND
PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMSXV
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM 2
CO
WATER SYSTEM
GRADING
cu. 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 a�
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESlINITIALS
GARDEN WALL FINAL