PLBG (0101-113) + BLCK (001908)52250 Avenida Madero
0101-113
001908
LICENSED CONTRACTOR DECLARATION
1 hereby'affirm-drioer penalty - 6f perjury that I am licensed under provisions of
4_`Shlapter 9,(commencing with Section 7000) of Division 3 of the Business and
Professionals Cod6; and my License is in full f6rce and effect.
License # Lic. Class Exp. Date"
D V Signature of Contractor
7 IF
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
icense Law for the following reason:
) 1, as owner of the property, or my employees with wages as their so,le
compensation, will do the work, and the structure is notintencled or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusively contracting with licensed
co , ntractors to construct the project (Sec. 7044, Business & Professionals
I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION, DECLARATION.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700. of the Labor Code, fo the
erformance of the work for which this permit is issued.
( ). I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the Oerformance of the work for which this
permit is iss . Lied., My workers' compensaticin insurance carrier & policy - no. are:
C arrier Policy No.
STATE FUM 229-00 UNIT 000"N
(This sectior; need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performarnke of the work for whi.ch this permit is issued,
I shall not employ any person in any manner so as to' become subject -to the
workers' compensation laws ofCalifornia, and agree that if|should become
subject to the workers' compensation proyisions . of Section 3700 of the Labor
Die o
.4 Applicant
rs I Brag; is unlawful and
shall subject an employer to criminal penalties anclj i Xvines up to $100,000, in
addition to the cost of compensation, damagds as provided for in Section 3706
of'the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subjqct to the conditions and restrictions set forth on his
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work ioperformed under o,pursuant to. .
any permit issued ooaresult ovthis opp|inamn agrees to, &oxan. indemnify
, m hold harmless the City m'uoOvinta. its officers, agents and employees.
. 2.Any permit issued auo result ofthis application becomes null and void if
work is not commenced within 180 uuyo from dam of iaovonPo of such
pemnh, or cessation bf workhnr 180 days will subject permit mcancellation.
|oertify that | have noi; this application and state that the above information io
correct. | agree tocomply with all Qty, and State |o*o relating mthe building
~conmmvnun, and hereby authorize representatives o,this City menter upon
the above-mentioned property for inspection
Signature n oo
BUILDING PERMIT. -t-,
DATE VALUATION LOT TRACT,
JOB SITE
APN I
ADDRESS
WILT", RUSISTELL
USE OF PERMIT
Do i's
101 -000-4.19-000
LESS PRE -PAW 1 -WO
T$i L'kil, , F -I 'DUE
1430AW
. ,
ECEIPT I'DEA"
VA By-
DATE FI ALED
INSIDE
_/
rr
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL, APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer ConnectionS
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final / A-7—
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Nonce (Perm)
COMMENTS:
•
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL `
08203
Received From: ` z'; r [' .! j ! ✓ QFC lC) { Date:
Address: Ii , C i
f _ 41c
Account No. ! %(r"• 2 , r'/'z % Lots) /J= k Tract i•
' Service Address 4---Z' 2' i l-7 t 11 ,I. 1 2:li G.A. Code
, ❑
Meter(s) $
❑ Service(s)
❑ Backflow(s) _ <
• c._ ❑ 'House Lateral(s) ., •
❑ Detector Check(s)
• j ❑ Meteor Surcharge
' Sanitation Capacity Charge
7
•.t
❑ W.S.B.F.C.
` ❑. Temporary Construction Meter
{ ❑ Turn on Charge '
❑ .Uncollected. Account -Name
❑ Inspection Fee - Tract - '
Fee-
.0
ee-
•❑ Plan Check Fees Water I Sewer - '
Tract -
❑ Bond Payment - A.D: - Bond
Assmt. ,
I' ❑ Customer Deposit
❑ Other
TOTAL $
1 Remarks:
RCopy to: ,
• Water Service —
Cash i, f j
i Check f°! i C !
- r r' Cashier-
Z,
Money' ;
Order , CV D-438(11189)
:" '
44
P.O. BOX 1504 No 001908
Building 78-105 CALLE ESTADO
Address 52—M AVeni& Mxxro LA QUINTA, CALIFORNIA 92253
Owner
BUILDING: TYPE CONST: OCC: GRP.,
Mailing
Address p.T,B= 136 A.P. Number
CityZip Tel. ll
linta
J92253 564-1544 Legal Description !.
Contractor Project Description '
it ii T -k :t i" , ate=•! r • .
Address . ... . ... .
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 it 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 ordinance's and state laws relating to building
construction, and hereby authorize representatives of this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant NX, ..1 - l ? ,, - Date
Mailing Address /
City, State, Zip %
r e ac tom enter Llne—
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line '
FINAL DATE INSPECTOR
Issued by:. Date d-' Permit
Validated by:
Validation:
A3400 11. 22 : 20.50 Ck•
HARD COPY
.100. f of. 4
igh U-nk
City
Zip ...
Tel.... _.,
State Lia
& Classif.
City
Lic. # -
Sq. Ft., No.
Size- Stories
No. Dw.
Units • -
Arch:, Engr.,... .- . _ ... -
Designer
New'❑ Add ❑ Alter ❑
Repair ❑' • Demolition ❑
Address
Tel.
City
Zip
State
Lic. #
:. .. ,...... .
LICENSED CONTRACTOR'S DECLARATION "
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
70 OO) of Division 3 of the Business and Professions Code, and my license is in full force and
effect. .. ..
M
;-
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, 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) of
Division 3 of the Business and Professions Codd, -'or that. he is exempt therefrom, and ther.basis
' for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for permit
subjects the applicant to a'clvil penalty of not more than'five hundred dollars (5500).
0 I, as -owner of the property, or my employees with wages as their sole compensation, will .
do,lhe 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•did_not build or improve for thepurpose of sale.)'
❑ I; as owner of.lhe property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Coder The Contractor'sLicense 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 I am exempt under Sec. B. 8 P:C: for this reason
Estimated'Valuation . y i e qyy
' a7' • IUP,. 00
- -
- " PERMIT - •' -
-• -
-
- ". AMOUNT'
'
- _
'Plan Chk. Dep. -
Plan Chk. Bal..
Const. '
q
20.00
Mech.
'
Electrical
Plumbing
S.M:I.' -
.
.5
Grading
Driveway Enc.
/
Date I Owner V+7 . t>^'= } i-. i -
Infrastructure
WORKERS' COMPENSATION DECLARATION . .
kehereby affirm that I have a certificate of consent to -self -insure, ora certificate of
Worr's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. ,Company
❑ CopyJS filed with the.city..., O 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 (S f 00) 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: If, after making this Certificate of Exemption you" should become
' subjecf'to the Workers' Compensation provisions of the Labor' Code, you must forthwith -
comply with such provisions or this permit shall be deemed revoked.
'
TOTAL«
REMARKS
-
,
ZONE: BY: -
Minimum Setback Distances: • -
F ont S tb k f C
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 it 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 ordinance's and state laws relating to building
construction, and hereby authorize representatives of this city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant NX, ..1 - l ? ,, - Date
Mailing Address /
City, State, Zip %
r e ac tom enter Llne—
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line '
FINAL DATE INSPECTOR
Issued by:. Date d-' Permit
Validated by:
Validation:
A3400 11. 22 : 20.50 Ck•
HARD COPY
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® $
2ND FL. SQ. FT. ®
POR. SQ. FT. ®
GAR. SO. FT. ®
CAR P. SQ. FT. ®
WALL SQ. FT. ®
SQ. FT. @
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPIEOUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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.
SO. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/a c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
REMARKS:
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 APPIEOUIP.
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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
m.IVN"J zsiur Al untwir IIAUk
FINAL