07433 (PLBG)P.O. BOX 1504 No. 0743
Building 78-105 CALLE ESTADO
Address "-Ste Te la LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Y. Licki c BUILDING: TYPE CONST. OCC: GRP.
Address PO' RON 345 A.P. Number 774'234`M2
City Zip Tel.
>� 3 S A
Legal Description Lot 13
2
Contractor Project Description S1IaL9PY' th hifflme—
JdeS. Pllbin Service
Address
52-M :eve, Villa .. ;
City Zip Tel.
State Lic. City '
& Classif. .337SS9- Lic. # 102 Sq. Ft. No. No. Dw. i
Size Stories Units
Arch., Engr.,'
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑',:
Address ' "• Tel.
CityZip State
Lic.#
-- /'' LICENSED CONTRACTOR'S DECLARATION
I hertgy afftG�n that 1 am licensed under provisions of Chapter 9 (commencing with Secti � n -
7000) o Division 3_-of-the:Business and Professions Code, and my license is i ull force nd
effect. 1 14�
SIGNATII �._ QNTE
w7 OWNER -BUILDER DECLARATION Estimated Valuation
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 rile a signed statement that he is licensed pursuant to PERMIT AMOUNT
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of '
Division 3 of the Business and Professions Code, or thathe is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit Plan Chk. Dep.
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 Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const.
Professions Code: The Contractor's License Law does not apply to an owner or property who —
builds or improves thereon and who does such work himself or through his own employees, Mech.
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 Electrical
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- Plumbing
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 S.M.I.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) .
Grading
O I am exempt under Sec. B. 8 P.C. for this reason
Driveway Enc.
Date Owner Infrastructure �•
WORKERS' COMPENSATION DECLARATION
Ihereby affirm that I have acertificate 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.
TOTAL $30.00
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS' COMPENSATION INSURANCEg
(This section need -not be completed if the permit is for one hundred dollars ($100) valuation Ldp' � .' `{';, '}'^" � w io,
or less.)
I certify that -in the performance of tha 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`' '
NOTICE TO APPLICANT: ,If, after making this Certificate of Exemption you should become ZONE: BY:
subject to the Workers'. Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances:
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) Side Setback from Property Line
Lender's Name .
Lender's Address' FINAL DATE INSPECTOR
This is a building permit when properly filled out, signed and validated, and is subject to yp
expiration if work thereunder is suspended for 180 days. � �AA�rf
1 certify that I have read -this application and state that the above information is correct. Issued by: Date GO 1 rmit
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. Validated by:
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMB&G,FEES
1ST FL. SO. FT. @ $
UNITS
COLL. AREA
2ND FL. SQ. FT.
YARD SPKLR SYSTEM
POR. Sp, FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. @
POWER OUTLET
ROOF DRAINS
CAR P. SQ. FT. @
DUCTWORK
DRAINAGE PIPING
WALL SQ. FT.
DRINKING FOUNTAIN.
SQ FT @
HEATING (FINAL)
URINAL
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
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
GRADING
cu. yd.
$ plus x$
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
BOILER. B.T.U.
SO. FT. @ c
BATH TUB
SQ. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID @ 1Vi c
SEWAGE DISPOSAL
FIREPLACE
SQ.FT.GAR @ 3Yac
HOUSE SEWER
SPARK ARRESTOR
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
116EWERONK
ROUGH WIRING
DUCTWORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATEF
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 / (� k
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICTgg
CASH RECEIPT DETAIL 8
Received From: 7-o,/),, / G Z `i (� �i "� -7 Date: v
Address: n Q K 3 �5 , Cr [ J t n fay �io-2 -�
Account No./-!? a - a-'7 Lot(s) Tract
Service Address % %- .3/� �Li .11p . Term es-�.� G.A. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s) "
Q House Lateral(s)
❑ Detector Check(s)
❑ Meter Surcharge
---Q Sanitation Capacity Charge 6.:5 /! 7S, Oy
❑ W.S.B.F.C.
❑ Temporary Construction Meter
S
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
i. Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
• TOTAL
}
Remarks:
❑Copy to:
CashWater Service
Check 10i -
Money <:kA " Cashier
Order ik
• _ CVWD-438(11189)
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