11870 (PLBG)t,- 44Qum&
K P.O. BOX 1504
�—� 78-105 CALLE ESTADO
Addrdacgc 52-315 vax a.'z LA QUINTA, CALIFORNIA 92253
Owner
Daniel X. 6canny
Mailing
Address P.0, Box 7
City
Izip
Tel.
Palm Vesert, CJ
322610
..564-3251,
Contractor_'
3avik- �iumbing
Address
P.O*' Bax 868
City
Tia Quinta., CA
Zip
9223
Tela
5641158
State' Lic..
City
& Classif. C-36 368143
Lic• # 1852
Arch., Engr:,
Designer- '
Address
Tel. ,
City ( Zip ( State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am Iicehsed under provisions of Chapter 9 (commencing with Section
7000Tof Divisio 3 gj�he Bu mess and Professions Code, and my license i� II fobce and
Vef f ecL• l/
SIGNATURE —�' � �d"ATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am,Aenipt from the Contractor's License Law for the following
reason: (Sec. 703 1.5, Business and Professions Code: Any city orIcounty which requires -a
permit to construct; alter, improve,- demolish, or repair any structure, I 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 i5cense 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds'or Improves. thereon anis 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 pursuant to the Contractor's License Law.)
❑ 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 self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
1 WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
V' sc)" i
I certify that in the performance of lhg work �ti which this permit is issued, I shall not
employ any pers2in any manner so as o eco subject to the Workers' Compensation
Lawsq California t
Date _ �_ Omer
NO C TO APP, ICdWE, If, after makin t isa' dificate of Exemption you should become
subject to the Workers' Compensation rovisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
p "
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
No. 11870
BUILDING: TYPE CONST.
A.P. Number
Legal Description
Project Description
OCC: GRP.
Sewer Connect
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$900.00
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
kd'AIJ*'A:4ia �W*r : Vg --:Sq °.dila,6 10,
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. Q $
UNITS
SLAB GRADE
(� 1
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
SEWE 2
'2 ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
FOR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SO. FT. ®
FINAL INSP.
WALL SQ. FT.
WATER SYSTEM
DRINKING FOUNTAIN.
GRADING
cu. yd.
$ -Plus-X$-=$
URINAL
SO. 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.000L 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, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER I
BOILER B.T.U.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1+/a c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
FINAL INSPECTION a.,
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
SEWE 2
'2 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
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION a.,
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATUREJINITIALS
GARDEN WALL FINAL
r
• i
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL f
Received Fro C L Srr► "_ ,� i'
Address'
t
f 2 4230
Account No. ACIG Lot ) • `Tract SG UI >� ti. -
Service Address
ServiceAddres8 4 = — R' G.A. Code t
❑ Material $ �.
❑ Service(s) h.
❑ Backflow(s)
i
❑ House Lateral(s) t
D DetectorCheck(s) �t 4
i
D Meters rcharge
D station Capacity Charge L!� _.l.l J •;' ��
725,°
D W.S.B.F.C. i'
❑ Temporary Construction Meter
D Turn on Charge "
D Uncollected Account - Name
r
D Inspection Fee -Tract - V
Fee - `
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
D Customer Deposit
`
D Other
t`
TOTAL
$
Remarks:
❑Copy to:
Cash
Water Service
Check
1757
[
Money
Cashier
Order
�.
CVWD- (11/89)
I