09096 (PLBG)P.O. BOX 1504 I N O . 09096
Building 78-105 CALL
E ESTADO
Address 54-685 Rwirez. LA QUINTA, CALIFORNIA 92253
Owner,
s p_vF'FranzBUILDING:. TYPE CONT. OCC: GRP.
Mailing
Address saume
A.P. Number
City izip ITel.
Contractor
Address
ty jZip
State LiaI City
& Classif. Lic. #
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 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).
I, as owneroI the property, or.my employees with wages as their sole compensation, will
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 notintended 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.)
❑ 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) licensed pursuant to the -Contractor's License Law.) -
,v
exempt under "Sec. B. & P.C. for this reason
r:. 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„b? 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 it the permit is for one - hundred dollars ($100) valuation
or less.)
I certify that in the performance of the 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: It, 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
Legal Description
Project Description Cess,rear 911ok-.Up
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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:
Validati
Sq. Ft.
Size
NO. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
const.
30.00
Mech. `
'Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
3& .00
REMARKS
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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:
Validati
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
2ND FL. SO. FT.
COLL. AREA
YARD SPKLR SYSTEM
POR. S0. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. I SO. FT.
FORMS
DRAINAGE PIPING
WALL SO. FT.
ROUGH WIRING
DRINKING FOUNTAIN.
SO. FT. ®
DUCT WORK
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GAS (ROUGH)
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
OTHER APPJEGUIP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED.
GROUT
LAUNDRYTRAY
AIR HANDLING UNIT CFM
f
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 ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
REMARKS:
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 APPJEGUIP.
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
Az"
REMARKS:
VENTILATION
FIRE ZONE ROOFING
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
COACHELLA VALLEYiWATER,DISTRICT a
CASH CEIPJ,DETAO;
Received From: � •s' r - � -�' _
Date:
Address -
Account N
ddress:AccountN j .�,' . . • I
Tract Si
Service Address= '�-
G.A. Code
❑ Meter(s) `
0 Service(s)
❑ Backflow(s)
❑ House Lateral(s) r.
❑ Detector Check (s) #
❑ Meter Surcharge }
�SanitationCapacity.Charge,
❑ W.S.B.F.C.-
❑ Temporary Construction Meter ' �,°
H
❑ Turn on Charge
i
❑ Uncollected; Account -Name
❑ Inspection Fee - Tract -
Fee - I
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Boni7'
Assmt.
❑ Customer Deposit
❑ Other : x
1
TOTAL $ J�L7 Q
Remarks:
❑Copy to:
Cash
z.: Water Service
Check / LG c--'"
Money J ' (I
Order Cashier Y
CVWD-438 (11/89)