08213 (BLCK)54-200 Cortez
Owner
One Li Cal si
City j Zip
Izip
T4'1t u
P.O. BOX 1504
78-105 CALLE ESTADO'
LA.QUINTA, CALIFORNIA 92253
State-L:ic. y
& Classif. ____ _ Cucit. #
Arch., Engr:,
Designer
Address Tel.
City IZip I Licit#
LICENSED CONTRACTOR'S DECLARATION
I herebyy:affirm,thet 1 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
effects .
SIGNATURE.- DATE
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the following
reason: (Sec.. 7031.51Business and Professions Code: Any city or county which requires a
permlf to ,construct, alter, Improve, demolish, or repair any structure, prior to Its issuance also
requlres 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 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, Bulsness and
Pro%ssions' 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 oroffered 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 notbuild or Improve for the purpose of sale.)
0 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 Lew.)
❑ 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 selVinsure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. ,Company
❑ Copy isJiled 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 (5100) valuation
or less:)
I certify that in the performance of the work for which this permit is Issued, I shall not
employ any parson in'any manner so as to become subject to the Workers' Compensation
Laws of California. '
Date Owner
NOTICE TO APPLICANT: H, after making this CertlRcate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must, forthwith
comply with such provisions or this perm/t.shall be deemed revoked..
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit Is Issued. (Sec. 3097, Ch11 Code.)
Lender's Name
Lender's Address
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 certifythat •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
Malting Address
City; State, Zip
No. ®8213
BUILDING: TYPE CONST. OCC: GRP.:
Number
Legal Description
Project Description Block W1
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const. 72.00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc..
Infrastructure
TOTAL 79 115
REMARKS ,
i V !'d - V 3 "ira'
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 713190 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL, SO. FT. ® $
UNITS
SLAB GRADE
2ND FL. SO. FT.
BONDING
YARD SPKLR SYSTEM
POR. Sp. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. Sp, FT,
POWER OUTLET
ROOF DRAINS
CAR P. I 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.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP,
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
� �
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
SPARK ARRESTOR
SO. FT. c
WATER HEATER
MAX. HEATER. OUTPUT, B.T.U.
SO. FT. REBID 1'A c
SEWAGE DISPOSAL
SO.FT.GAR @ Yic
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PLCK.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 APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plug x$
=$
LUMBER GR.
FINAL INSP,
FRAMING
FINAL INSP.
ROOFING
T
� �
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
�'?•
Al
COACHEL LA VALLEY WATER DISTRICT
RECEIPT DETAIL
c/
/� }
ta•
Trac
/Iddrese !J
Z2
C.A. Code ;
I:
$ j:..
] $e doehl
�7 ,BpdIflOM(e)
( ti
`��Hauee Lateral(a)
- � `
Cepaclty Charge
5 tN8 B F.C.
O Construction Meter
w
;Temporary
V;
'-O- AmonCharge
'''O
Wicolleeted Account- Name
:O Inepectlon Fee - Tract -'
Fee-
Check Fees Water GSewer -
}
Tract -
P;d� Blond Payment - A.D. - Bond
7 's
,,Y i~,!�• Asemt.
I:c
r'Y�
• i gid: -_�,
r V�4 Vii.
TOTAL
Y,
Remarks n • w
Cish WaterBervloe
Money`�� ; Caehlar j �r