13392 (PLBG)P.O. BOX 1504
Building 51-682 Ave. Aamirez 78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Owner Victor H. Owen, III
Mailing BUILDING: TYPE CONST
1601 Civic Center Dr. 0203 1
ess
%VA'nta Clara, da"' 95050
nt
00arlitiory
Plumbing
Addr
461s180
Clinton Street
City
Zip
Indio,
CA
*2201
State Lic.
& Classif.
273088
Arch., Engr.,
Designer
Address
No. 13392
_OCC. GRP.-
1A.P.. Number
Te
60W84-699 Legal Description
I11Pr . oject D . escription sewer connect
Tel.
347-3629
City
Lic.# 101
Tel.
City Zip State
I I Lic. #
LICENSED CONTRACTOR'S DECLARATION
I herebtpf�firm that I a In licensed under provisions of Chapter 9 (commencing with Section
7000' lot ivision 3 of the Business and Professions Code, and my license is in full force and
effec .
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 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 five hundred dollars ($500).
0 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 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
o7fp. ovi . ng that he did not build or improve for the purpose of sale.)
h .
t�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 contractorts) licensed pursuant to the Contractor's License Law.)
0 1 am exempt under Sec. -B. & P.C. for this reason
_14-t. "19 '/Owner A fAe(� r,
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 4, 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
0 Copy is filed with the city. 0 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 thp 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.
Dale_Owner
NOTICE TO APPLICANT., ff, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions of 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 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 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
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Lin
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
—Side Setback from,Pr.�—Perty_Line
FINAL DATE INSPECT
Issued by:
Validated by:
ay
Validation: __Z1 ,
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New 0 Add El
Alter 0
Repair El Demolition 0
Estimated Valuation
1_4
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
2
Plumbing
16.
S.M.I.
Grading
Driveway Enc.
Infrastructure
30.
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Lin
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
—Side Setback from,Pr.�—Perty_Line
FINAL DATE INSPECT
Issued by:
Validated by:
ay
Validation: __Z1 ,
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. @ $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT. @
FORMS
SEWER
ROUGH WIRING.
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. @
GAS(ROUGH)
METER LOOP
GAR. SO. FT. @
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO. FT. @
GROUT
WATER HEATER
WALL SO. FT. @
FINAL INSP.
DRINKING FOUNTAIN.
BOND BEAM
WATER SYSTEM
URINAL
SO. FT. @
LUMBER GR.
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
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
VENTILATION
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIRE ZONE ROOFING
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FIREPLACE
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 @ 3/4c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT.FEE
SMIFEE PLUMB. FEE
STRUCTURE . I 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 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. 1
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 SIGNATURESIINITIALS'
GARDEN WALL FINAL
Received
Address:
Account No. (1-1
Service Address
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
N 0. '� 4 7 94.4 �
if U , I U) - V) Lot(s) I Tract �_ )7,k I �7(rA_� % ( I IQ
t A� 'N tli�
I A r-1.
• Meter(s)
• Service(s)
• Backflow(s)
• House Lateral(s)
• Detector Check(s)
• Meter Surcharge
P,"S'anitation Capacity Charge E5 �7,_
• W.S.B.F.C.
• Temporary Construction Meter
• Turn on Charge
• Uncollected Account - Name
• Inspection Fee - Tract -
Fee -
0 Plan Check Fees Water / Sewer -
Tract -
• Bond Payment - A.D. --Bond
Assmt.
• Customer Deposit
• Other
TOTAL $
Remarks: t\
0 COPY to:
Cash WaterService
Check
05 '01
Money
CV'WD-438 (11189)
Cashie, �Sv\_)
Order