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13816 (PLBG)Tlihf 4 4 a" , Buil�ing 52-945 Ave. Rubio Address Owner Ms. Sandxa Dierks Address Same CityTel Tel. La Quintal 92253 Contractor Hendrickson Construction, Inc, AdE SP46615 Kieley Road P.O. BOX 1504 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 "1:.athea3raI Ci4'_"",' CA 9223 C'(6-9) 328-174 State Lic.65QI67 City �� & Classif. Lic. # Arch., Engr., Designer Address Tel. City Zip State Lic. If LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division3 of the Bysiness and '!e gt"ons Codeqand my license is in full force and 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) or Division 3 of the Business and Professions Code, or thathe is exempt therefrom, and the basis for the alleged exemption. Any violation or Section 7031.5 by 'any applicant for a permit subjects the applicant to a civil penalty or 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, 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 or completion, the owner -builder will have the burden or 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.) ❑ 1 am exempt under Sec. B. & P.C. for this reason Date 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' 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 thg 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 subject to the Workers' Compensation provisions or 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 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 sof this city to enter the above-. mentioned property for inspection purposes. Signature of applicant -Date- Mailing ateMailing Address City, State, Zip BUILDING: TYPE CONST P. Number No. OCC. GRP.; Legal Description Project Description Sever Connect 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 DAl Issued by:_ Validated t Validation: rmit n 1 Sq. Ft. Size No. No. Dw. Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation $2t240.00 PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing 30.00 S.M.I. Grading Driveway Enc. Infrastructure TOTAL 30.00 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 DAl Issued by:_ Validated t Validation: rmit n 1 CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES IST FL. SQ. FT. ® $ UNITS SLAB GRADE ROUGH PLUMB. BONDING YARD SPKLR SYSTEM 2ND FL. SQ. FT. FORMS SEWER ROUGH WIRING. MOBILEHOME SVC. BAR SINK POR. SQ. FT. ® GAS (ROUGH) METER LOOP GAR. SO. FT. ® POWER OUTLET ROOF DRAINS GAS (FINAL) TEMP. POLE DRAINAGE PIPING CAR P. I SO. FT. ® GROUT WATER HEATER WALL SQ. FT. FINAL INSP. DRINKING FOUNTAIN. BOND BEAM WATER SYSTEM URINAL SQ. FT. ® _$ LUMBER GR. ESTIMATED CONSTRUCTION VALUATION $ FRAMING WATER PIPING NOTE: Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES REMARKS: 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 CFM 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. SQ. FT. ® c BATH TUB SO. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 1+/a c SEWAGE DISPOSAL FINISH GRADING SQ.FT.GAR ® 3/ac HOUSE SEWER GAS PIPING PERMIT FEE MIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE EPL.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 ROUGH 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. ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION Qr/ v J CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES/INITIALS GARDEN WALL FINAL O COACHELIA VALLEY WATER DISTRICT HE CASH RECEIPT DETAIL Z� �55 . Received Address: C i / - U- "r . - :7'7r /--:.Gr ,/ /...C... _. C X01 Account No. L;. ' ot(8� a✓G r-- / Tract Service Address G.A. Code ' llI I ❑ Meter(s) $ ❑ Service(s) ❑ Backflow(s) ;. ❑ House Lateral(s) " "'O"D`e'tectorCheck(s). r ..k. ,�.:� ,.�:�.��.•�.";x� .. .-.. - _ .. .. .. xyai ❑ Meter Surcharge. �Sanitation"CapacltvCharoe ❑ W.S B.E C. z.rti° p Temporary:ConstructionMeter +.r 0 Turn on Charge ❑ Uncollected Account= Name x "_ ❑ Inspection Fee -Tract ` • Fee _ _. - . %. ❑ 'Plan Check Fees Water I Sewer , Tract,- >i =;Bond Payment-A:D..- Bond '7� } , :.. - Assmt. a. Y _ ❑ Customer Deposit y ❑ Other t' T $ a.. (��-� 5 TOTAL Remark s 7%l %f ! C a eco , to: �. WeterService. Check' Money Order Cashier e C - (11189)