10861 (PLBG)P.O. BOX 1504
Building
'Address 54-105 .JUAItEZ LA QUINTA, CALIFORNIA 92253
Owner
WX. CUSACK
Mailing
Address 74-225 HWY 111, STE. C
CityZip Tel.
PALM DESER 82260
Contractor
CUSACK S ASSOC/SANTA COSA CONST.
Address
74-225 HWY 111, STE. C
PALM DSSERT SAME
State Lic. City
& Classif. 565814 Lic. # 1253
Arch., Engr.,•
Designer,
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm,,,,t4M l am lider provisions of Chapter 9 (commgncing with Section
7000) of Division 3 of the BtTsineJss d Professio s Code, and my lice/nse*is it full orce"a7n�d
effect. ,: dP.7 �% /
.SIGNATURE !� d i 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, atter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to lila 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 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 improvementsare 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 a contractor(s) licensed pursuant to the Contractor's License Law.) -
0 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificatte,df consent to s It -insure, or a certi "eat
Worker's Compensation Insurance, or a certified copy thereof/.qSec. 3800e.)
Policy No. Company �16'�
❑ Copy is filed with the city. ❑ 6ee6fied 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, l shall not
=any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner '
NOTICE TO APPLICANT: If, alter 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
No. 10861
LDING: TYPE CONST. OCC: GRP.
P. Number
-gal Description
•oject Description SEWER R0n1ZTIV
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ -Demolition ❑
Estimated Valuation
$1,000
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
$30.00 **Voss
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
$30.00
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
IST FL. SQ. FT. ® $
2ND FL. SQ. FT.
POR. SO. FT. ®
GAR. SQ. FT. ®
CARP. SQ. FT.
WALL SQ. FT: ®
Sq FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
r
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation _
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT. WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
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.
SQ. FT. ® cBATH
TUB
BOND BEAM
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1% c
SEWAGE DISPOSAL
LUMBER GR.
SQ.FT.GAR ® 3Y.c,
HOUSE SEWER
FINAL INSP.
ROOFING
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
GH WIRING.
DUCT WORK
ROCK STORAGE
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 SIGNATURESHNITIALS
GARDEN WALL FINAL
Remarks:
0 COPY to:
Cash
Check
Money
Order
Water Service
Cashier—L'\ 2 2
CVWD-438(11/89)
COACHELLA VALLEY WATER DISTRICT
144
CASH RECEIPT DETAIL
CC.),*"QA Irc I(A
z:�
4-,2
Received From:
Address:
Li 2%
Date-
Account
nt No.
Lot(s) Tract
ii� L C�,
Service Address '2
A Q S i G.A. Code
• Meter(s)
$
• Service(s)
• Backtlow(s)
• House Laterals)
• Detector Check(s)
• Meter Surcharge
Capacity Charge /Q/
I _ZQ_
Plfanitation
0 W.S.B.F.C.
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
0 Inspection Fee - Tract -
Fee -
0 Plan Check Fees Water I Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
C3 Customer Deposit
0 Other
7
TOTAL
Remarks:
0 COPY to:
Cash
Check
Money
Order
Water Service
Cashier—L'\ 2 2
CVWD-438(11/89)