15276 (PLBG)P.O. BOX 1504
Building44— 77'5 Highland Palms LA OUINTA, CALIFORNIA92253
Address.-c� �. � '
Owner J®hh me11a
Mailing
Address Same
City Zip Tel.
La QUinta If CA. 92253. . -
Contractor
Address
Zip I Tel.:
State Lia. I City
& Classif.. Lic. #
Arch., Engr.;•
'Designer "
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
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 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) o/
Division 3 gf the Business and Professions Code, .or that. he is exempt therefrom, and the basis
/or th Iligad exemption. Any violation of Section 7031.5 by 'any applicant for a permit
sub) is the applicant to a civil penalty of not more than rive hundred dollars ($500). . 1.
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, Buisness and
Professions Code: The Contractor's License, Law does not apply to an owner o/ 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, thebuilding
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 o/ 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) pcensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B J& P.C. for this reason
ate+ r Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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'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 asfto become su ject to the Workers' Compensation
flaws of C_allfornia fi•'
`Date. d !�7 Owner
NOTICE TO APPLICANT: H, after making this Certificate of Exemption you should become
subject to the Workers' Com,6ensation 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 3708 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.
1 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-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
}
No. 25276
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number
Legal Description
Project Description Sewer Connect .
Sq. Ft-
Size -
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
I±
Estimated Valuation
$1 ! 000 . 00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk- Bal.
Const.
Mech.
Electrical
Plumbing
30.00 "
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
35. 00
REMARKS
ZONE: BY:
Minimum.Setback Distances:
Front Setback
Rear Setback
Side Street SE
Side Setback
FINAL DATE
Issued•by:
Validated by:
Validation:
)m• Center Line
I%.-rPlrro`p. Line
13�c/k/from Center Line
ram Prope y LAl
ln�e
NSP
ECTOR
0Pe miit
e
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBINU FEES
1ST FL. SO. FT. ® $
2ND FL. SO. FT. ®
POR. SO. FT. ®
GAR. SO. FT, ®
CAR P. SO. FT. ®
WALL SO. FT. ®
SO. 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.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEOUIP.
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/. c
SEWAGE DISPOSAL
� V-1- / Awe
�/
SO.FT.GAR ® 3/.c
HOUSE SEWER
VENTILATION
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 R
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
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
� V-1- / Awe
�/
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
1 VMZ1 JIMMAI WMrWINII IALJ
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From:'
Address: �l — ��`! 1_N/f y .,�•- / _�
Account No. Lot(sl
Service Address'!,
ddressl�':-�.�,i / •:o%m
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
Sanitation Capacity Charge .S
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee -Tract -
Fee -
13 Plan Check Fees Water I Sewer -
Tract -
13 Bond Payment - A.D. - - Bond
Assmt.
❑ Customer Deposit
❑ Other
Remarks:
❑Copy to:
a4i6c
Da p
Tract
G.A. Code
S
�f
TOTAL E S �CJG
t '
Water Service -•�'"
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Cashier
CVWD-E38 (1llaal