14517 (DSF)Building
Address
4
P.O. BOX 1504
78-495 CALLE TAMPICO .
77-270 Calle Chihuahua LA QUINTA, CALIFORNIA 92253
Mailing
Address 51-060 Avenida Herrera
City Zip Tel.
La Quinte 192253 1 564,2256
Contractor
. owner/builder
Address
City Zip . Tel.:
State Lic. I City
j & Classif. Lic. #
4 Arch.; Engr.,
Designer
I Address Tel.
City ( Zip ( 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 Professions 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. S,Business ,and Professions Code: Any city or county which requires a
permit to construct, after, 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 Section 7000) or
Division 3 or 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
su 7ects the applicant to a civil penalty of not more than Ove hundred dollars ($500). -
I as owner of the property, or my employees with wages as their sole compensation, will .
do he work, and the structure is not Intended or offered for sale. (Sec. 7044, Buisness and
Professions 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 -builder will have the burden
of proving that he dM not build or improve for the purpose of sale.)
O 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 contractors) licensed pursuant to the Contractor's License Law.)
❑ 1 amaxem • t under Sec.— y B. & P.C. for this reason
Or
Date Ownerx
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
O Copy is filed with the city.. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE•
(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
aliforniaDate Owner
NOTICE TO APPLICANT: O, 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. •
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE•COST OF COMPENSATION,
DAMAGES AS PROVIDEDFOR IN SECTION 3706 OF -THE LABOR CODE, INTEREST, AND
ATTORNEYS FEES.
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.
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 enter the. above-.
I mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip •
LDING: TYPE CONST
P. Number 273-31-1-03-2
No. 14517
OCC. GRP.:
,Legal Description
Project Description Demolition of existing"
structure prior - to new construction.
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk: Dep.
Plan Chk. Bal.
Const. 45. AO
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
Validated
Vaiidatior
CONSTRUCTION ESTIMATE
V !
NO. ELECTRICAL FEES
NO. PLUMBINii
COLL. AREA
$
UNITS
BONDING
1ST FL. SO. FT. ®
sT
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
YARD SPKLR SYSTEMa°
2ND FL. SQ. FT. ®
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GROUT
WATER HEATER
SERVICE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
GRADING
cu. yd.
$ plus x$
=$
DRAINAGE PIPING
CAR P. I SO. FT.
FINAL INSP.
FRAMING
FINAL INSP.
WALL SO. FT.
ROOFING
DRINKING FOUNTAIN
SO. FT. ®
REMARKS:
URINAL
ESTIMATED CONSTRUCTION VALUATION
$
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
LATHING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
I
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
FENCE FINAL
SO. FT. ®c
BATH TUB
INSPECTOR'S SIGNATURESIINITIALS
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
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 APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
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
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL