04792 (BLCK)T4ht 4 4 Q"
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address
City Zip Tel.
Contractor
Address
City lZip (Tel.
State Lic. City
& Classif. I Lic. #
Arch., Engr.,
Designer
Address Tel.
City I Zip State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
70W) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
5[GNATuRE 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 requfras a
parm,r to construct, alter, rmprova, damolish, 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) of
Division 3 of 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).
❑ 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 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 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.)
O 1 am exempt under Sec. B. & P.C. for ttiis reason
Dale 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 the work for which this permit is issued, I shall not
employ any parson in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner _
NOTICE TO APPLICANT: If, 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 thls applleatlon and state that the above information Is correct.
1 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
mentloned property for inspection purposes.
Signature of applicant v Dale
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number
Legal Description
Project Description
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Eric.
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 HATE
Issued by:
Validated by:
INSPECTOR
14/ ;,
Date Permit
Mailing Address
City, State, Zip
Validation:
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE
ELECTRICAL FEES
NO. PLUMBING FEES
UNITS
UNDERGROUND
A.C. UNIT
YARD SPKLR SYSTEM
MOSILEHOME SVC,
BAR SINK
POWER OUTLET
ROOF DRAINS
HEATING (ROUGH)
DRAINAGE PIPING
FORMS
DRINKING FOUNTAIN
SEWER OR SEPTIC TANK
URINAL
DUCT WORK
WATER PIPING
FOUND. REINF,
FLOOR DRAIN
GAS (ROUGH)
WATER SOFTENER
;IGN
WASH ER(AUTONDIS HI
REINF. STEEL
GARBAGE DISPOSAL
GAS (FINAL)
LAUNDRY TRAY
KITCHEN SINK
TEMP USE PERMIT SVC
WATER CLOSET
DOLE, TEM/PERM
LAVATORY
kMPERES SERV ENT
SHOWER
SO. FT. ® c
BATH TUB
SQ. FT. (g c
WATER HEATER
Q. FT. RESID 114 c
SEWAGE DISPOSAL
SQ.FT.GAR rg Vic
HOUSE SEWER
FINAL INSP.
GAS PIPING
)ERMIT FEE
PERMIT FEE
ROOFING
CONST. FEE ELECT. FEE
SMI FEE PLUMB FEE
HEATING 8 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 APP.IEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
�/ BOND BEAM /
//
(� (/
AAA
WATER SYSTEM
GRADING
cu.yd.
S —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
INSPEC70R'S SIGNATURES/INITIALS ,
GARDEN WALL FINAL