10289 (PLBG)P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 53-210 Avenida Ramirez •LA QUINTA, CALIFORNIA 92253
Owner
Mele^.i£9 Sauceda
Mailing
,@
Address
citta ui?2'�a Zi Tel. Te1.564--3636
Contractor
Address
Zip
State Lic.
City
& Classif.
Lic. #
I
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, alter, 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 licensedpursuant 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 or not more than five hundred dollars.(8500). .
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 of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
O 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 or 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.C. for this reason
Date Owne)4tff�- n "I f � f`t ti.'
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 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. t
Date Owner r ✓i �' F t f 4Y l i
NOTICE TO APPLICANT: �U! 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 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 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
It.
No. 10289
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
Legal Description
Project Description
Sewer. Hook Up
Sq. Ft. No. No. Dw.
Size Stories Units .
New ❑ Add ❑ Alter ❑ Repair ❑ -Demolition ❑
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 DATE
INSPECTOR
Issued by: — Date Permit
Validated by:
Validation:
Estimated Valuation
200.00
PERMIT
AMOUNT
Plan .Chk. Dep.
Plan Chk. Bal.. .
Const.
Mech.
Electrical
Plumbing
30.00
S.M.I:
Grading
Driveway Enc.
Infrastructure
4 f�l)Cl i'k� �* CFe tii
x %^idr --�'�)14
TOTAL
30. ou
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 DATE
INSPECTOR
Issued by: — Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING 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.COOL 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,TEMIPERM
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 ® 1+/4 c
SEWAGE DISPOSAL
A4� All�
SO.FT.GAR ® Vhc
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 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
A4� All�
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
Av 1�f C 0A CHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From:AA 777
Address: —I -S- —i VO& Vvi V)�w1-1
t
Account No. SO 0, t(s) jract
Service Address k2'
Code i'
0 Meter(s) $
0 Service(s) f
eV
0 Backflow(s) _J . z;;,
0 House Laterals)
0 Detector Check(s)
0 MeterSurc6rge .
F}''ghltaiion Capacity Charge
0 W.S.B.F.C.
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account Name
13 Inspection Fee -Tract -
Fee -
0 Plan Check Fees Water Sewer -
Tract -
13 Bond Payment - A.D. --Bond
Assmt.
0 Custom6r Deposit
O.Other
TOTAL
Remarks:
ECONO SEWER SERVICES
P.O. Box 192
3.70 6
PALM DESERT, CALIFORNIA 92261 ,
PHONE 328-7760 346-2793
/\
_
-CUSTOMER'S OR ER O.ELI—M C
...
H L ER
TIN T
WILL TO
^
ORDER KEN BY
ADDRESS
WORK ORDERED BV
TOTALAMOUNT
40 DAY WORK
O CONTRACI
EXTRA
JOB NAME A U LUCATIO
_
PHONE
jEI
D�CT3I�IONO��
- PUMENT_SERMS-NET-IO-DAYS-f-R "AIE-OE_SERlA��
1%% PER MONTH CHARGE AFTER 30 DAYS
_ TOTAL MATERIALS
_
TOTAL LABOR
--PLEASE -PAV-f RAM-THIS-4NVAI
NO STATEMENT WILL BE MAILED TAX
DATE COMPLETED
WORK ORDERED BV
TOTALAMOUNT
$
0 No one homeI
Tot amount due 0 Total bilEng to
f above work: or be malld after
Signature compleCon
PROD= M2 N2vs Ix 1 hereby acknowledge the satisfacmpletion Of work
Dwo� xm oun. of the above described