12473 (PLBG)Building 52-060 Velasco
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P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Owner Lindau Harshall
Mailing P.O.'Box 13146
Address
CityZip Tel.
La QuintaB. C� 92253 1 564-1599
Contractor
owner/Builder
Address
City lZip I Tel.
State Lic. City
& Classif. Lic. #
Arch., Engr.,
Designer xN
Address Tel.
City I Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I 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,Susiness 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 o/ the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 o/ 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 /or a permit
' subjects the applicant to a civil penalty o/ not more than five hundred dollars ($500). "
sal `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 o/ completion, the owner -builder will have the burden
o/ proving that he did not build or improve for the purpose o/ 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.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date 7 f`'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. Company -
[I 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 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�tfie' Workers' Compensation
Laws of Californi : • }
�Oate`� -�y' ," '�,Owne
TNOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
TTTTT 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. 12473
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
$1,230.00
PERMIT
AMOUNT
PIan.Chk. Dep.
Plan Chk. Bal.
Const.
Mech. ''
e
Electrical
,w w
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
r
n ea n n j
TOTAL
REMARKS
D
ZONE: BY: nnr n n W11I
VV 1 4.1 vYIJI
Minimum Setback Distances:
Front Setback fro• Center, Line
Rear Setback fro r ° Prop. Line
Side Street Setback-•from-Eenter Line—
{ Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
I
CONSTRUCTION ESTIMATE I NO. I ELECTRICAL FEES NO. I PLUMBING.§EES
IST FL. SQ. FT. ® $
UNITS
UNDERGROUND
A.C. UNIT
COLL. AREA
YARD SPKLR SYSTEM
2ND FL. SQ. FT. p
BONDING
HEATING (ROUGH)
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
DUCT WORK
ROCK STORAGE
FOUND. REINF.
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
OTHER APP.IEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SQ. FT. @
GROUT
WATER HEATER
SERVICE
FINAL INSP.
DRINKING FOUNTAIN.
WALL SQ. FT.
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
URINAL
SQ. FT.
FINAL INSP.
FRAMING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FIRE ZONE ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIREPLACE
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.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
FORMSSEWER9&SEPTIC
TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEQUIP.
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 SIGNATUaES/1NITIALS
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT 51(.14-1s,
/ j Q �Q j
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CASH RECEIPT DETAIL 51 (b / q
Received From: , iy?fidSK� L L Z4/,4All-IA _WQ-16 La. Date:
Address: " GC- n /LL ff' t'pi C%)�'.n ? Z
Account No. •� (i 7 ! rO' ` Lots) Tract—S
Service Address 02 - CC) 11y V Z C- S C G G.A. Code
❑ Meter(s)
❑ Service(s)
❑-, Backflow(s)
❑ House Laterals) r'
❑ Detector Check(s)
❑ Meter Surcharge -7
o tation Capacity Charge i s
ani
t`
❑ W.S.B.F.C. 1
❑ Temporary Construction Meter `
O Tdrn on Charge l
' ❑ Uncollected Account -Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water 1 Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other —y
TOTAL $ Z /i
• ' Remarks:.
❑Copy to:
Water Service -
Cash ( I
I Check OI
Money CVWD-438 (11189)
Order
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