15579 (PLBG)Building
Address 51-160 Calle Palma
Owner
teeter Murray & Assoc.
Mailing
Address 78-417 Hwy. 111
City Zip
La. Quinta, Cs.. 92253
Contractor
Mumbil, Inc.
Address
P.O. BOX 1555
Cit
a Quinta, CA Zip92253
State Lia 537333
& Classif. "
Arch., Engr.,
Designer.
Address "
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Tel. 564-1338
City 2526
Lic. #
Tel.
City IZip I State I
Lic. #
I herebyyyy affirm that IAT licensed undegprovigions 6f Chapter 9 (commencing with Section
fD00)' f'Divisjon�3 of B, usina,, an rof sstQ 'ons Code, and my licen — fultab� and
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 thathe 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 rive 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 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.)
❑ 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 contractors) pcensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
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, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. I Company
Iy 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 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. 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 1 have read this. application and state that the above information is correct.
1 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. 15579
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number
Legal Description
Project Description Sewer Connect
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$1,000.00
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
Rear Setback from RearRrop. Line
Side Street Setback from Center Line
Side Setbaclyfro Prope y`JLine,
FINAL DATE `A INSPECTOR
Issued by: Date X Permit �►.
19
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBINU FEES
1ST FL. SO. FT. $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT.
FORMS
SEWER SI}(
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
CARP. SO. FT. ®
GROUT
WATER HEATER
WALL SO. FT.
FINAL INSP.
DRINKING FOUNTAIN.
SO. FT. ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
_$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING '
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
LATHING
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
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE FPLUMBFEE
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 SI}(
ROUGH WIRING
DUCT WORK
ROCKSTORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
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
REMARKS:
VENTILATION
FIRE ZONE ROOFING '
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES11NITIALS
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT
CASH
-
r
RECEIPLDETAIL
Received
From:
Address: Z 13 >
Date:- "SA
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_ Account No. lr �% /11N%L �7J
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Lots)
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Service Address f' (•fin U C n �C- r'
` O 1^^ G--
Tract
G.A:,Code.
.
❑ Meter(s)
J.
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❑ -Service(s)
0 Backflow(s)
❑ House Laterals)•
' DetectorCheck(s)
-
.�❑ Meter Surcharge
Sanitation Capacity Charge
:❑ W.S.B.F.C.
..i -
;�❑ Temporary Construction Meter
.❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
1
Assmt.
�❑ Customer Deposit
-❑ Ogrer
-
TOTAL
E.
Remarks:
❑COPY to: ..
Cash
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