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15490 (BLCK)ceit�t 4, a V 0 6J 4�,� ��_ -- P.O. BOX 1504 No. 15490 Building 78-495 CALLE TAMPICO Address �� nt `� _ �:C11: � :�_+.., -.-: ri LA QUINTA, CALIFORNIA 92253 Owner Mailing Address City Izip ITa L Contractor Address Zip State Lic. j City & Classif. I Lic. # Arch., Engr., Designer Address Tel. City I Zip State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that 1 am licensed under pfovisions 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 I hereby affirm that I am exempt from the Contractor's License Law for the failowlng reason: (Sec. 7031.5,Susiness and Professions Code: Any city or county which regllire5 a permit to construct, alter, 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) 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 penally of not more than five hundred dollars (S500). ❑ 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 contraclor(s) licensed pursuant to the Contractor's License Law.) ❑ 1 am exempt under Stec. __f3. & 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 Code.) Policy 1,10-. -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 lt tleo permit is for one hundred dollars fS100) vahmlion or less-) I certify that In the performance of thg work fof•,which this permit is issued, I shall nol employ any person In any manner so.as to become subject to the Workers' Compensation Laws of California. f _ Date Owner ,c NOTICE TO APPLICANT: 8, after making this Cefff r-ate of Exemption you should bacoma subject to the Wvrkrrs' 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 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S 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 reiating to building construction, and hereby authorize representatives Hof 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. P. Number Description Project Description Sq. Ft. No. Size Stories No. Dw. Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation3l� ) 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�� Pit Validated by: 1 Validation: n t� CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SQ. FT. a 2ND FL SQ. FT. (r� POR. SO. FT. aIMOBILEHOMESVC. GAR SQ. FT. Ca CAR P. SQ. FT. ® WALL SO. FT. ® SQ. FT. @ ESTIMATED CONSTRUCTION VALUATION $ UNITS YARD SPKLR SYSTEM BAR SINK POWER OUTLET ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL $ WATER PIPING NOTE: Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASH ER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CAM KITC.HFN 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 ® 1 Vi c SEWAGE DISPOSAL SQ.FT.GAR ® Y4c 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.0 UNIT COI 1 . ARFA SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCKSTORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APP./EOUIP. REINF. STEEL GAS (FINAL) IEMY. PVLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING cu. yd. $ plus x$ =$ LUMBER GFL FINAL INSP. FRAMING FINAL INSP ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGN ATiIRESfINiTIA1.5 GARDEN WALL FINAL