11222 (PLBG)Building 53
Artrir .. 54 9195 Cortez
T4'!t 4 4 414
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Cusack & Assoc.
Mailing
Address 74-225 Hwy $21 Suite C
City x'.De IZI92260 ITe1568-0855 I
arta Rasa Construction
same as above
State Lic.I City
& Classif. 565814 Lic. # 2001
Designer
Address
City IZip IState#
E ED CONTRACTOWS:DECLARATION
that _IIrfnnsed under provisions of Chapter 9 (commencing with Section
1, .1 1—
. LIA
r. -
:r ' OWNER•BUILDERIDECLARATION
I hereby affirin that 1 am exempt from the Contractors License Law for the. following
_ reason: (Sec. 7031.5,13uSEness and Prof sssions Code:' Any city or county which requbm a
permit fo construct, 'alter, improve, demolish, or repalr :any structure; - prior to Its ftKW Ce also
requires Mea 1Xw,t for such permit to We a sknod statement that he Is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 8 (commencbg with Section 7000) of
Diviaton 3 of the Business an& Pwresslons Colo, or that. he Is exempt thershom, and the basis
for the alleged exemption. Any violation - of Section 7031.5 by any applicant for a permd
subjects the sppikant to a civil penafy of rat more than five hundred do8ars.($500)..
❑'t, as owner of the property, w my employees with wages as their sole compensation, will
do the work, and the. structure is not Intended w offered for.eals. (Sec. 7044, Buisness and
Professions Code:. The Comractoes 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,
pavw fhet such Improvements are not,intended or offeredforwale. f, however, the building
or Improvement Is sold within one year of completion, the owner-Mdlder will have We burden
of proving the" he did not build or improve for the purpose of sets.).
0 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions -.Code: The ControcWs License Law
does not apply to an owner of property,who builds or improves Bnerson, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.) I -
❑ 1 am exempt under Sec. a, g 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
Workers Compensatiorr.lnsurance, or a certified copy thereof. (Sec. 3800, Lebor.Code.)
PPAcy No- Company .
AU Copy Is filed with the city. 0, Certified copy is hereby.fumished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be competed If the pend[, Is for one hundred abfans (6100) Valuation
or less:)
I certify that in the performance of the work for which this permit is issued, I stall not
employ arry pperson In any manner so as to become subject to the Workers' Compensation
laws of Callf0 iL
Date Owner
NOTICE TO APPLICANT: f, after malag this CorMde or Exemption you should become
subject to, the Wbr*ers' Compensation' provisions of the Labor Code, you must lorthwfh
comply with such provisions or this pemdt 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 permiit Is Issued. (Sec. 3097, Cirf Code.)
Lenders Name _—
Lenders Address
This Ise 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 1 have read this application and state that the above Inforrnation'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. 11222
BUILDING: TYPE CONST. OCC: GRP.
Number
Legal Description
Project Description
Sewer Hook Hp
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ -Demolition ❑
Estimated Valuation
1.r5Eld
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 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. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SO., FT.
FORMS
EWER offmmp"e-rAw'L z
POR. SO. FT. 0
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. I SO. FT. ®
OTHER APPJEOUIP.
DRAINAGE PIPING
WALL SD. Ff.
TEMP. POLE
DRINKING FOUNTAIN,
SO FT ®
GROUT
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
=$-
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOXDISH) .
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
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
SPARK ARRESTOR
SO. FT. 0 c
WATER HEATER
MAX. HEATER OUTPUT, B:T.U.
SO. FC RESID ® 1% c
SEWAGE DISPOSAL
LATHING
SO.FT.GAR a 44c
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
EWER offmmp"e-rAw'L z
OUGH 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 xt
=$-
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 SIGNATURESRNITIALS
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: — Cxk4 e 1`� LOL VN Cj
Address: 1 , • 11 1
Account No. Lot(s)
Service Address 51 P t < < O ( fc
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Laterals)
❑ Detector Check(s)
❑ Meter Surcharge
1—�..
ErSani(aflon Capacity Charge .
❑ WS.B.F.C.
❑ Temporary Construction Meter
❑ Tum on Charge
❑ Uncollected Account - Name
❑ Inspection. Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
• Bond Payment - A.D. - Bond
Assort:
❑ Customer Deposit
❑ Other
Remarks:
❑Coov, to:
Tract �— I
G.A. Code.