15021 (PLBG)P.O. BOX 1504
Building 78-495 CALLE TAMPICO
Address 46-770 Cameo Pains LA QUINTA, CALIFORNIA 92253
Owner Michael a Raren Piper
Mailing '
Address ►siime
City Zip Tel.
.La Quanta, CAS 9,2253.
Contractor
D & G plt3E'[1bing
Add
es
r X 90 Gravel Pat Act..
7000 Palms, C47 92276 343-29$8
State Lic._ City
& Classif.. x-36. 6»8226 Lic. # 156
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
1s'- . ... 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 rile 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 or 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 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 orsnproves 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.)
Al, 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) (rcensed pursuant to the Contractor's License Law.)
O 1 am exempt under Sec ? B. & P.C. for this reason
Date % Owner { .JG' i.-Y� . ' t x ✓ir,t+ t rt
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's C�tion Insurance, or 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 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
Date - 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 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 properly 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
No. 15021
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number
Legal Description
Project Description 01ewer Connect
.
r
Sq. Ft.
Size- • •
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ .
Demolition ❑
Estimated Valuation;
I
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
30.00
S.M.I.
Grading
Driveway Enc.
"
Infrastructure
TOTAL
30.00
i
ZONE: BY: E ; ,/ t 1' U
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line i
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 N
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
2ND FL. SO. FT.
-
YARD SPKLR SYSTEM 6
POR. SD. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P.' SO. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SD. 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 ® 1+/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ic
HOUSE SEWER
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
SEWE OR��
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.
® j 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 SIGNATURESJINITIALS
GARDEN WALL FINAL
Rdcelved
Adllress:
Account#
Service A
COACHELLA VALLEY WATER DISTRICT N
1 CASH RECEIPT DETAIL
❑ Meter(s)
❑ Servlce(s)
❑ Backflow(s)
❑ House Lateral($)
_
❑ Detector Checks)
❑ Meter Surcharge
OManitatlonCapacity Charge
❑ WS.B.F.C.
❑ Temporary Construction Meter
❑ Tum on Charge
❑ Uncollected Account - Name
❑ Inspection Fee- Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. --Bond
Assml
❑ Customer Deposit
❑ Ot)ier
TOTAL S ��g
Remarks:
❑Copy to:
Cash
-
Water Service
Check
L
Money
v
.
Cashier,
0rder
'
f VWD-rse(11M)
COMMENTS 1 ' .. - '
3E .IACHkn rts�;FucTldr�S . �n , `.,I
SERVICES ACCEPTED SUBJECT TO THE TERMS AND CONDITIONS ON THE REVERSE SIDE AND PAYMENT AGREED TO BE MADE IN ACCORDANCE WITH THE
CONTRACTOR'S CURRENT RATE SCHEDULE.; r -
CUSTOMER i' y CONTRACTOR ,,�
SIGNATURE '"> SIGNATURE
CIMS -0038T (10/90) WHITE — OFFICE YELLOW — CUSTOMER PINK — CONTROL { printed on recycled paper. O
r
4Vacte Management of the Desert „
41575 Eldeft St
2553,15'
Palm D=crt, CA 82280
810-,340-2113 610-324-1741
ORDER NUMBER
SERVICE DATE -
y
PO# I-
071131 t+
5/09/95 s
SERVICE TICKET AGREEMENT/NON-HAZARDOUS WASTES
TIME IN
TIME OUT
DIVISION
NUMBER
ACCOUNT SERVICE',
3 6 18 n I NUMBER Z 018 Z 2 0 TYPE PO
CUSTOMER
P I P EK1 M I K E
ROUTE ID
DISPOSAL ID
DISPOSAL TICKET
121 ..
ADDRESS
:��-77t) t,;Ala PAL/J
SIGNATURE
COD
AMOUNT
CITY
LAQUIP TA .... 92253 '`' ` :..19
NOT -REQR
ACTION
ORD QTY
SERVICE DESCRIPTION
WASTE TYPEI BILL
CObij
MEASURE BILL QUANTITY
AMOUNT
COMMENTS 1 ' .. - '
3E .IACHkn rts�;FucTldr�S . �n , `.,I
SERVICES ACCEPTED SUBJECT TO THE TERMS AND CONDITIONS ON THE REVERSE SIDE AND PAYMENT AGREED TO BE MADE IN ACCORDANCE WITH THE
CONTRACTOR'S CURRENT RATE SCHEDULE.; r -
CUSTOMER i' y CONTRACTOR ,,�
SIGNATURE '"> SIGNATURE
CIMS -0038T (10/90) WHITE — OFFICE YELLOW — CUSTOMER PINK — CONTROL { printed on recycled paper. O
r
TERMS AND CONDITIONS OF SERVICE AGREEMENT
WASTE MATERIALS. Customer warrants that the waste materials delivered to Contractor hereunder will not contain any hazardous, toxic or ~
radioactive wastes or substances as defined by applicable federal, state, local or provincial laws or regulations nor any special wastes as defined by
y Contractor (Form No. WMNA-0038AD). Contractor shall acquire title to the waste materials when loaded into Contractor's vehicles; provided,
however, that title to and liability for the waste materials excluded from this agreement above shall remain with Customer, and Customer agrees to
indemnify, defend and hold harmless Contractor against all claims, damages, suits, penalties, fines and liabilities for injury or death to persons or loss
or damage to property or the environment arising out of the breach of the warranty stated above.
CUSTOMER'S RESPONSIBILITY FOR EQUIPMENT. Customer shall be responsible for all loss or damage to the equipment, other than normal
wear and tear and except for loss or damage resulting from Contractor's handling of the equipment when providing its services hereunder. Customer
shall not overload or move the equipment or make any alterations or improvements to the equipment, and shall use the equipment only for the proper
purposes for which it is intended. CLIstomer shall be liable for any overweight fines caused by an overload condition.
Customer agrees to indemnify, defend and hold harmless Contractor against all claims, damages, suits, penalties, fines and liabilities for injury or
death to persons or loss or damage to property arising out of Customer's use, operation or possession of the equipment.
On collection day, Customer shall provide unobstructed access to the equipment. If the equipment is inaccessible, Customer will be notified and
charged for any additional collection service or attempts to provide such service.
CHARGES AND PAYMENT. Customer shall pay Contractor in accordance with Contractor's established rates for the services provided. Where the
Schedule of Charges specifically indicates "disposal" as a component of the charges, "disposal" shall mean the posted gate rate for disposal at the
disposal facility utilized by Contractor plus an appropriate handling charge.
Customer shall be liable for all taxes, fees or other charges imposed upon the disposal of Cusfogier's waste materials by federal, state, local or
provincial laws and regulations.
Payment shall be made by Customer yoithin ten (10) days after receipt of an invoice from Contractor. Contractor may impose, and Customer agrees
to pay, a late fee not to exceed the maximum rate allowed by applicable law for all past d -e pZ44wents.
PAVEMENT DAMAGE. Contractor shall not be responsible for damage to {'1.1stomer's gement or other driving surface resulting from the weight of
Contractor's vehicles servicing the equipment location designated by CustoN r.
ATTORNEY'S FEES. In the event of a breach of this. agreement y either party, the breaching party shall pay al reasonable attorney's fees,
collection fees and costs of the other party incident to any action hroiinht to enforce this agreement.
10/90