14387 (PLBG)4
P.O. BOX 1504
Addyjng 54-4 35 . Ave. Rubio LA QUINTA, CALIFORNIA 92253
Address
Owner • T leu Brown Anmin stratrix
Mailing SaM
Address
CityZip Tel.
Lan Quinta, CA 92253
Contractor
Huiaibil Inc4l,:
A V 21113'5 ' Cobalt Way
-'Palm Deaert, 92260
State Lic. S, 537333
& Classif. .
' Arch.; Engr., .�
Designer
No. 14387
BUILDING: -TYPE CONST. OCC: GRP.
A.P. Number
Legal Description
Sever Connect
Project Description.
Te1.55A-1338
City 25G
Lic. # Sq. Ft.
Size .
Address' =4- Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereb ,afji�at I am licensed under pPovisions of Chapter 9 (commencing with Section
'� ) of'�ivision of the�pusiness and Professions Code, and my license is in full force and
ffect� �•'.��
SLGNATU E 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 rile a signed statement that he Is licensed pursuant to
the provisions of the Contractor's License Low, 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 penalty of not more than rive hundred dollars ($500). .
O 1, 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 Low does not apply to an owner of property who
builds or Improves thereon andwho 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 knprove for the purpose of. sale.) _ -
O 1, 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) jrcensed 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 I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, ora certified copy thereof. (Sec.•3800, Labor Code.)
Policy oe1 Company
UI Copy Is filed with the city. . ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM 1
WORKERS' COMPENSATION INSURANCE i
his section need not be completed ompleted 1l the permit is for one hundared 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 pperson in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: 'B, after making this Certificate of . Exemption you should become
subject to the Workers' Compensation provisions of the. Labor Code, you must forthw(W
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.
Ttiis 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 1 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. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
*10P(i U °
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech. '
Electrical
Plumbing
40.1 L10
•S.M.I.
'
Grading
Driveway Enc.
Infrastructure
TOTAL
0
REMARKS '
ZONE: BY:
Minimu'rri Setback Distances:,
Front Setback from Center Line
Rear Setback from Rear Prop.. Line
re tback from Center Line
Sid etb rom Property Line '
FINV,U ATE_
Issue bAEC
Validlated by:
Validatiori:'
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBIW FEES
IST 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` h
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 APP./EQUIP.
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 ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR p 3/ac
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 OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
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
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From:
Address: %
Account No. 7`. '? =?X, L t(s)
ServiceAddress
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
Remarks:
❑Copy to:
Cash
Check
Money
Order
Tract-
G.A. Code
TOTAL
Water Service
Cashier_- L�
CVWD-438 (11/89)