13752 (PLBG)4
Building
Address
Owner
52--050 Ave. Cortez
Boyd G. Newbold
Mailing 2368 Foothill Lane
Address
City Zip
Brea, CA $262.1
Contractor
Owher/Buil dor
Address
Zip
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
BUILDING: TYPE CONST
Number
No.
OCC: GRP.:
Lot 19 Block 38
(714) 990-0520 Legal Description
Project Description SeB er, Connect
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City _ IZip _ IState I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 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
effect.
SIGNATURE _ 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, alter, improve, demolish, or repair any structure, prior to its issuance also
requires 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).
154as 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 a contractor(s) licensed pursuea�n't,to the Contractor's License Law.) /{
❑ 1 am exempt under C. for this reaso A
<Date r ' 1/9 .sSfiC�i`'i,, ?/ k
X ' r
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. Company
O 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 sYor one hundred'dollars ($100) valu
or less.) ,f.. J'
I certify that in the performance of-thg work for whiph thisapermit is issued, I shall
employ any person in=any manner so=as to become.96biectlto the Workers' Compen7
Laws oWalifornia:�g� •^ti F
NOTICE TO APPLICANT: It, after making thisl Certificate of Exemption you should bec
Subject to the Workers' Compensation provisions of the Labor Code, you must fortl
,*omply 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 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
13752
i
l '
Sq. Ft. No. No. Dw.
Size Stones Units _
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation $1,000.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
30.00
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
30.00
REMARKS
_ -It
y$
{
ZONE: BY: NV y
Minimum Setback Distances: V`
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
i
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. • SO. FT. ® $
UNITS
COLL. AREA
1
YARD SPKLR SYSTEM
2ND FL. SO. FT. Q
HEATING (ROUGH)
STORAGE TANK
POR. _ SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
FOUND. REINF.
DRAINAGE PIPING
CAR P. I SO. FT. ®
HEATING (FINAL)
OTHER APP.IEOUIP.
WALL SO. FT. ®
DRINKING FOUNTAIN
SO. FT. ®
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.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FINAL INSP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEMIPERM
LAVAqHEATER
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOW
BOILER B.T.U.
SO. FT. ® c
BATH
FIREPLACE
SO. FT. ® c
WATE
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWA
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 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
1240SEW57
UGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEOUIP.
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
AL INSPECTION >-
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
C.OACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL n,
Received From: Data:
Address:
Account No. Lot(s) de_
Service Atli resa O.A. Code
❑ Melei'm $
❑ Service(s)
❑ Backflow(s) .
❑ HouseLeteral(s)
❑ Detector Check(s)
❑ Meter Surcharge
71 �Sanitatlon Capacltycharge �,— 4 n
❑ W.S.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
Assmt.
❑ Customer Deposit
❑ Other
TOTAL
Remarks:
❑Copy to:
hWater
Service
ck
l'
�ta
Money
Cashier
Order
7\/�/e'
�.A' CMD -0.181111891