10536 (PLBG)Building y
OririrCCC a 52- 321 Velasco
Terry Miller
4 44
Z�1 rfi�/
P.O. BOX 1504 .f i �'v Q, 10536
78-105 CALLE ESTADO I I i
LA QUINTA, CALIFORNIA 92253 r i
BUILDING: TYPE CONST. til OCC: GRP.;
Mailing
Address P. 0. Box 1.342
City Zip Tel.
La Quinta 92253 564-3492.
Contractor
O'amer/Buiider
p
State Lic.I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City Zip 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,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). -
�I,_as owner of the properly, 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, Businessand 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
14
Date Owner/•d�3'' .' 4/ %aI!•-x�'f�f 1
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 certifled.copy.thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ 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 thg work for which this permit, is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.,{
Date Owner �r ✓ ,/f`.�✓f��
NOTICE TO Al LICANT:�%I, "after 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 '
1 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
A.P. Number
,Legal Description_
Project Description
-Seder Hook Up
Sq. Ft. No: No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation- -
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
r r%e;-t c 11 4 ?% '?,14 ' r, 4
f.� _�� -. ASH 1- ..TOTA 1 60 UU
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
1ST FL. SO. FT. ® $
UNITS
"
2ND FL S0. FT.
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. 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.000L 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, TEMIPE RM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER. B.T.U.
SO. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SO.FT.GAR ® -/ac
HOUSE SEWER
LATHING
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
If SEWER OR4621ICSpNK
ROUGH WIRING.
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER L60P
HEATING (FINAL)
OTHER APPJEOUIP.
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 l 3
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
It
T
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL��,b
1.
Received From: 'l
t
x
L2 �Q
Address:
Account No.
�f n
Date:
Lot ) Tr8
�• �'e. 47
Service Address
1
G.A. Code
❑ Meter(s)
$
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
(
t
❑ DetectorCheck(s)
❑ Meter Surcharge
Xanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn 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:
Cash
/
Water Service
Check
Money
A I
Cashier 1
Order
CV1ND- 438 (t t /89)
It