12131 (ADD)Building
Address
" Owner
4
P.O. BOX 1504 N o .
78-105 CALLE ESTADO
52-120 Vallejo a LA QUINTA, CALIFORNIA 92253
Robert .& Elisabeth
Mailing
. Address P.D. Box 1694
City. Zip Tel'
•..- .Tndic , C� 92202 564-4944
Contractor ;
t vnerlBnild6r ,
Address
City Zip Tel.:
,State Lic. 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) t.of Division 3 of the Business and Professions Code, and my license is in full force and
effec, ,
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 orjcounty 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) or
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 penally of not more than five hundred dollars (5500).
Cd�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
f`. 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 contractors) licensed pursuant to the Contractor's License Law.)
❑ .I am exempt under Sec. B. & P.C. for this reason `
;t D Owner
i.
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
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
NOTICE TO APPLICANT. If, 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
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 buildingpermit 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
12131
BUILDING: TYPE CONST. OCC: GRP..
A.P. Number
Legal Description
Project Description G`3i'aC, e' addition
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
•
Estimated Valuation $1.1o236.20
PERMIT
AMOUNT
1'
Plan Chk. Dep.
1 "
Plan Chk. Bal.
87.75
Const.
1'3.5, 00
Mech.
21.00
Electrical
36.49
Plumbing
INSPECTOR
S.M.I.
..44
Grading
Driveway Enc.
Validation:
Infrastructure
TOTAL
286.68
REMARKS
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
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT. @
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SO. FT. @
FINAL INSP.
WALL SO. FT. @
WATER SYSTEM
DRINKING FOUNTAIN.
GRADING
cu. yd.
$ —Plus—X$—=$
URINAL
SO. FT. @
FINAL INSP!— —a? 2J /W
FRAMING /�—��J�� Ly�
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, TEM/PERM
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
SO.FT.GAR @ 3/ac
HOUSE SEWER
FINAL INSPECTION
GAS PIPING
PERMIT FEE
ERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FVPL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE i PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
00,
GROUND PLUMEING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH 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!— —a? 2J /W
FRAMING /�—��J�� Ly�
FINAL INSP.? 2
�—
ROOFING/2 `V�
_ _ n / �i/� 2Jf /�
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
t/•
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNA—URESIINITIALS
GARDEN WALL FINAL
r NAM15L 1NJUKC;L: Jt1AKMAN�tCVlS15t('1•.W: ,`` �.
RATING'INFORMATION: 1.FAMILY MASONRY VENEER DWELLING_BUILT IN .19 51.
STATE. 04 TERR..79,PROTECTION CLASS 8
WITHIN 500 FEET OF A FIRE HYDRANT AND WITHIN 3 MI LES. OF A FIRE STATION
PREMIUM GROUP 1.15
FORMS AND ENDORSEMENTS NOW MADE PART OF THIS POLICY:
(ENTRIES ON ENDORSEMENTS MAY BE'LEFT BLANK IF SHOWN ELSEWHERE IN THE POLICY).
a H=03 04-84' HO .3 -'.SPECIAL FORM . ', BASICPREMIUM '$ 521.00
G-2911-0 07-83; AMENDATORY ENDORSEMENT PREMIUM NIL
H-23872 11-85''SPECIAL PROVISIONS CALIFORNIA PREMIUM NIL
HO -322 09-85 HOME DAY CARE EXCLUSION PREMIUM NIL
HO -325 12-85. COMMUNICABLE'DISEASE EXCLUSION PREMI"UM NIL
HO -216 04-84 PREMISES ALARM,OR FIRE PROTECTION.SYSTEM CREDIT $ 10.00
2•PERCENT CREDIT
H-370-0 09-85 REPL OR REPAIR COST — .COV :A PREMIUM $
H=266-0 06-83 LIFETIME CONTINUATION AGREEMENT. PREMIUM. NIL
H-323-0.: 04-84 PERSONAL PROPERTT REPLACEMENT COST PREMIUM $ 52.00'
HO-90CA 09-84WORKERS' COMP RESIDENCE EMPLOYEES' PREMIUM $ 5.00
CIGA:S:URCHARGE.,. $ 4.15
:•
TOTAL. PREMIUM .: $ .. _. 573.15
FULL PAY :SINGLE.BILL:.,'---------------------;--- ------
*THIS IS NOT.A BILL*
THE INSURED WILL RECEIVE A SEPARATE'STATEMENT.FOR PREMIUM4 DUE
a * PLEASE NOTE
;. RETIREE CREDIT APPLIES �.
i ACCOUNT CREDIT APPLIES
.108% OF THE REPLC :-COST
THE FOLLOWING ITEMS-ARE.ENCLOSED'FOR.YOUR•.REVIEW.
DRH-6-0 - IMPORTANT.NOTICE.
DRH-5-0 NOTICE
DRH-1-1 GOOD',: NEWS:
DRA-76-1 NOTICE OF .INSURANCE INFORMATION PRACTICE
DRH-104=0 IMPORTANT:NOTICE CA EARTHQUAKE COVERAGE
DRH=164-0 NOTICE TO POLICYHOLDERS,
---PAGE 2 OF 2----
`"
FORM H-250 (Ed. 10/84) MC,. 03-03-86 03-03-86,03-03--;86
..: .` . RIVERSIDE COUNTY SECURED PROPERTY TAX BILL —1992-1993 FISCAL YEAR
Telephone (714) 275-3900 o. (,�-I9) 363-8900
PropertyLOTS 17 & 18 BLK 76 MB 018%70 SANTA CARMELITA VALE
Bi�iNunwer
� es,i;aniN,,rnt;r,$11
773223023-9
Data LA QUINTA UNIT 10
0561416
Tax Rale Area
Pii- ;'l Number
' Address52120 AVENIDA VALLEJO LA QUINTA 92253
020-017
7732_23__023-9
4
OVINER ON
MARCH 1. 1992 SHARMAN, ROBERT �W TR & ELIZABETH TR
�
Land $
2T7_60--
• Charges Levied by Taxing Agencies (see item #4 on reverse)
Rate
Amount
Structures
44,180
GENERAL PURPOSE
1.00000
399.40
Fixtures
UNIFIED SCHOOL DEBT SV
.09750
38.94
Trees & vines
COMMUNITY COLLEGE DEBT SV
.00096
.38
Citrus Pest value
COACHELLA VAL WATER DEBT SERV (619) 398-2651
.02690
10.74
Personal Property
CITY OF LA QUINTA LDS & LTG (619) 564-2246
A
22.00
CITY OFwLA QUINTA WASTE DISP (619) 564-2246
A
103.08
$
--
46 940
LA QUINTA AD 91-1 (619) 54672246
A
208.62
Full Value
H O X
,
7,000
•
Less Exemptions:
Net value $
39,940
1.12536
Tax Rate per $100 value
Taxes . $
4 4 .46
B 10 0 7 9 2 (KEEP THIS PORTION FOR YOUR RECORDS)
Other Assessments
333
SHARMAN, ROBERT W TR & ELIZABETH TR
TOTAL AMOUNT DUE $
_
783.16
P.0 BOX 1694
LA QUINTA, CA 9 2 2 5 a'
1st lnstailment Recel . t
2nd lhstaliment Receipt
3918
391.58
Add 10%
Add 10".
penalty
penalty
IMPORTANT
UNPAID PRIOR -YEAR TAXES
atter
+ $10 cost
INFORMATION ON
(See, Item #6 or reverse) Tax•Delaull Year & Numbur
12/10/92
afu:i
"'—'REVERSE -SIDE "_ ..._. _-- .
_ _90022$Q190'
39.1_.58 _
391...58
-.�
4-4
No
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it
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