10784 (PLBG)Building 1;t ." s`j
Address
Owner
Mailing
Address
City Zip Tel.
" L x 1? a q
Contractor
Address
r
� J
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
City ZiR Tel
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State Lic. City
& Classif. � - 9 33.9 Lic. #
Arch., Engr.,
Designer
Address Tel.
City IZip ISt to I
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
! her affirm that I am exempt from the Contractors Lirenm Law for the following
reason: [Sec- 7031.5.Business and prdresslons Coda.- Any city or county whkh regL*vs a
Permit 10 canstrucl, alter, improve, demofish, or repair any struclure, prier to tts Issuance aim
requires the appNcant for such permit to fNe a si�nad statement Ihaf he o bcensed pursuant to
dta pmvistons of the Contractor's 1. cease law.
Chapter 9 (commenckV with Sectbn 7000) of
01miDn 3 of rho Business and Professhms Code, or that -he is exempt theretmrn, and the basis
for the alleged exemption. Any violation or Saetlon 7037.5 by any appfmam for a poma'i
subjects the appkcanf to a chvl penalty cl not more than live hundred donors (SU00).
❑ 1, as owner of the property, or my employees with wages as their sole compensation, wilt
do the work, and the structure is not intended or offered For sale. {Sea. 7044. Buisnoss and
Prblasslons Code: The Contractor's License Law does nor apply to m owner of property who
bands or Improves thereon and who does such work himself or through his own employees,
Provided that such improvements are not intended or offered for sake- 8, however, the braiding
or improvement is sold wllhin arse year of compkatron, the owner•buArder will have the burden
of proving that he did nor belNd or kMrove for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sac. 7044, Business and Professions Code: The Contractors Uconse 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 Contrmfor's License Law.)
❑ 1 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 Gode.j
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 it the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date_�__Owner
NOTICE TO APPLICANT., M, after making I N$ CarfiAcato of ExerWtiwr you should become
subject to the Workers' Compensation provisions of the tabor Cade, 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 application and state that the above information is correct
I agree to Comply with all city and County ordinances and slate laws relating 10 building
construction, and hereby authorize representatives -of this city to enter the above -
men t loned property for inspection purposes -
Signature of applicant— ,Date
Mailing Addres
City, State, Zip
No. 10784
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 ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep-
Plan Chk. Bal.
COnst.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL 3.0
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.
2ND FL.
POR.
GAR.
CAR P.
WALL
ESTIMATED CONSTRUCTION
SQ. FT.
SQ. FT. @
SQ. FT.
S0. FT. ®
SQ. FT. ®
SO. FT. @
SQ. FT. @
VALUATION
$
UNITS
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
Is
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
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT GPM
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
SQ: FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID @ 11/4 C
SEWAGE DISPOSAL
SQ.FT.GAR @ 3/ic
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEEN
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 QgAw*fi9 T*NK 013
.ACTUGH
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.
I
ROOFING
L 9
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION q
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIG NATU RESIINITIALS
GARDEN WALL FINAL