14848 (PLBG)44
uG!'Gv
C .&tyl
P.O. BOX 1504 N o . 14848
BufrdinAddtess J3"885 Ave. Ramirez LA QU NTA, CALIFORNIA 92253
owl;ar Glenn Brooks
Mailing S&Me'
BUILDING: TYPE CONST. OCC: GRP.
Address
A.P.Number
City Zip Tel.. .P.
La . Qui nta, CA92253 564-4776 Legal Description
ContractorSewer Connect
Omer/Builder Project Description
Address.
City
State Lic.I City
& Classif• Lic. #
Arcn., tngr.,
Designer
Address Tel.
City I
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 1 am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Busfness and Professions Coder Any city or county which requires a
permit to construct, atter, 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 o/ 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 o/ not more than rive hundred dollars ($500).
[[77 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 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 /or sale. If, however, the building
or Improvement is sold within one year o/ completion, the owner -builder will have the. burden
of proving that he did not build or Improvefor 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 contractors) (Icensed pursuant to the Contractor's License Law.) sss999
❑ 1 a+m� exempt under Sec. B. ByP.C. for this reason
;Date`' Owner.
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificateof 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. O 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 h@�lwork for whichothis permit is issuVOI shall not
employ any erson in any manner sof' . o become subj cfto the Workers' Compensation
w oOwnerteL�aOTIPCANT;
N, after 'making this Certificate - o/ Exemption you. should .become
subject to the Workers' Compensation provisions o/ 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 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
This'is a building permit when property 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 -of this city 'to enter the above
mentioned property for inspection purposes. .
Signature of applicant Date
Mailing Address
City, State, Zip
TOTAL 30.00
REMARKS
ZONE: BY:
Minimum.Setback Distances:
Front Setback from Center Line
r e. a ro ar Prop. Line
tree etba om Center Line
Side Sell f
tbacro` Dertv Line
FINAL DAT MAR'1�3:°19 ;5 I , CTOR ;
lu
u
Issued by: �''•DatePermit
By
Validated by:
Validation: `~
Z-
��. .,.
Sq. Ft.
Size
No. No. Dw.
'Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$100000
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
r e. a ro ar Prop. Line
tree etba om Center Line
Side Sell f
tbacro` Dertv Line
FINAL DAT MAR'1�3:°19 ;5 I , CTOR ;
lu
u
Issued by: �''•DatePermit
By
Validated by:
Validation: `~
Z-
��. .,.
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMPIW FEES
1ST FL. SO. FT. ® $
UNITS
—• ` *75
2ND FL. SO. FT.
BONDING
YARD SPKLR SYSTEM
POR. SO. FT.
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CARP. SO. FT. ®
GAS (ROUGH)
DRAINAGE PIPING
WALL SO. FT.
OTHER APPJEOUIP.
DRINKING FOUNTAIN.
SO. FT. ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FRAMING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
-
LAUNDRY TRAY
AIR HANDLING UNIT CFM
REMARKS:
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/ac
HOUSE SEWER
MESH
GAS PIPING
PERMIT FEE
ERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FrPL.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
SEWS OR SEJfP /
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. 3t��'
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
'
y
COACHELLA VALLEY WATER DISTRICT
' CASH RECEIPr DETAIL ' !
v 4246/.�
'Received "
-
`� , �'.
From:
Date.
Address:
'Account —1 Vr
'.Lot(s).
•Trac r
No.
-, Service Address
=
F G�:A. Code
-
❑ Service(s)
❑ Backtlow(s)
Y t •?
iwi1;
r. �.
4
a❑ House Laterals)
❑ Detector Check(s)
-
"
::.
1'
'
❑ Meter Surcharge
$Sffigtatlon Capacity Charge
a
WS.B.F.C.
•:•.
"Temporary Construction Meter
❑ Tum on Charge
'
y
. .6 Uncollected Account - Name
=
`A ` -
?
O Inspection Fee - Tract -
w
a Fee -
.:
x,❑ Plan Check Fees Water I Sewer -L
Tract -
_
' ❑ Bond Payment - A.D. - Bond
Assmt
,\-
❑ Customer Deposit
p
IVV
v
,.,
p other0
fd
OL
zm&
TOTAL 377
Remarks
� �
1,7
..;, _
T J
;
$
❑Copy to:
�.
Cash r7�/ S
Check ' `''
�.
?'
:4i
. Water Servl
r ,♦,
Cashier �
oney
IM
r.
-"
..
order
17
of
cvwo-utiiiveai'
9
Ve& Sew&"
Mailing Address: Box 1255 PALM DESERT, CA 82261
Phone: 328-6718 / 346.6916 -
Calif. State Cornractord' License No. 310813
Name ` D Bllito
Job at At
City zip
city aP
N? 65849
DATE
WORKMAN
—
13 Old Customer D New Customer
Classification.
Telephone ( )
WORK AUTHORIZATION - I / We hereby authorize the work described along with
the necessary materials and parts
WORK ORDERED:
Time From
To
Hours MATERIAL USED
AMOUNT
Mon.
Tues.
Wed.
Thurs.
Fd.
Sat.
/ V
Sill.
Trial Hours
Z°'✓�.
ENTERED
Invoice
Journal
Ledger
Cards
WAIVER OF RIGHTTo C"
Having Irtitlat'd a contrail in connection vn emergency
repairs or service for the 171 h9ate protectlon of persons g
ertargencyP si �n%td °requnng sirvneed� attentition.
Pursuant to section 1689.13 of the California Civil Code,
ac OV and hereby waive all rights to cancel the sale
within three days.
Dated Buyees Signature
TO OUR CUSTOMERS: Service men are required to have work slip signed. This is done in order to protect you, the workmen, and ourselves, and .
to enable us to give you absolute satisfactory service. You are respectfully requested to examine material and labor statement before workmen
leave the job, and If you find everything satisfactory, okay this ticket. If service Is unsatisfactory, In any way. please phone our office
immediately. I find the Unie and material charged above saustactory and res to kyr same on piesentabon o1 invoice, and further agree to
pay reasonable d►arges for collectlon, including attorneys lees in trig event �rW default' A PENALTY WILL BE CHARGED AT THE RATE OF
ttr% PER MONTH ON UNPAID BALANCES AFTER 30 DAYS OF INVOICE DATE. ANNUAL PERCENTAGE RATE 18%.
Contractors are required by law to be licensed and regulated by
theContractors'State License Board. Anyquestionsconcerninga signed
contractor may be referred to the registrar of the board whose
address is: Contractors' State License Board, 9835 Goethe Road, BY
Sacramento, CA 95827, P.O. BOX 26000, Sacramento, CA 95826.
TSI Matetfal
Tax
Service
P�`rf'�' Insurance
Trucks -Equipment
TOTAL
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