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15140 (PLBG)P.O. BOX 1504 Building 78-495 CALLE TAMPICO Address54-925 VALLEJO LA QUINTA, CALIFORNIA 92253 Owner C.OACHELLA VALLEY LAM Mailin Address79150 CALLS TAMPICO #230 City La Zip 92253 T l. .- 565522 Contractor owner builder Address City Zip State Lic.I City & Classif. Lic. # Arcn., tngr., 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)0! 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 1 am exempt from the Contractor's License Law for the following reason: (Sec. 7031.5,Busfness and Professions Code: Any city or county which requires a permit to construct, after, 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 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 applyto 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, Business and Professions Code: The Contractor's License Law does not apply to an owner of property whtqbuilds or Improves thereon, and who contracts for such projects with a contractor(s) licensed pursu Lto the CCoon_tn/cY'gr's License Law.) ❑ 1 am exempt under Sec. B°r8 P.C. fy �tT his r�eason�14 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, , O 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 ($10o) 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. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES'UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. 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 car lly 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 ateMailing Address City, State, Zip BUILDING: -TYPE CONST No. 15140 OCC. GRP. A.P. Number Legal Description Project Description SEWER HOOKUP ZONE: BY: 'a " Minimum. Setback Distances: Sq. Ft. Size . • No. No. Dw. } Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ 'Demolition ❑ Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by: Date Permit Validated by: Estimated Valuation 1200.00 PERMIT AMOUNT Plan Chk. Dep. . Plan Chk. Bal. Const. 30.00 Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL 30.00 REMARKS' ZONE: BY: 'a " Minimum. Setback Distances: Front Setback from Center Line I 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. PLUMBIW !CES 1ST FL. SQ. FT. ® $ UNITS SLAB GRADE ROUGH PLUMB. BONDING YARD SPKLR SYSTEM 2ND FL. SQ. FT. FORMS SEW R ROUGH WIRING MOBILEHOME SVC. BAR SINK POR. SQ. FT. ® GAS (ROUGH) METER LOOP GAR. SQ, FT. ® POWER OUTLET ROOF DRAINS GAS (FINAL) TEMP. POLE DRAINAGE PIPING CAR P. SQ. FT. GROUT WATER HEATER WALL SQ. FT. FINAL INSP. DRINKING FOUNTAIN. SO. FT. ® WATER SYSTEM URINAL ESTIMATED CONSTRUCTION VALUATION $ =$ WATER PIPING NOTE: Not to be used as property tax valuation FRAMING FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASH ER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED 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 SO. FT. ®c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 11/4 c SEWAGE DISPOSAL INSULATIONISOUND SQ.FT.GAR p 3/4c HOUSE SEWER FINISH GRADING 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 SEW R ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEQUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING cu. yd. g plus x$ =$ LUMBER GR. _ �j G&Al ��.. S FINAL INSP. FRAMING FINAL INSP. /`f ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURE:AINITIALS GARDEN WALL FINAL COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL Received From: �I '. �!.,4 Address: Z�t4 �- h..� .l " r�li Date: ' J Account No. �' Lo s) ` Tract• C ' Service Address �� '� ' G.A. Code ❑ Meter(s) $ ❑ Service(s) ❑ Backflow(s) ❑ House Lateral(s) ❑ DetectorCheck(s) ❑ Meter Surcharge Sanitation 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 r ❑ Other J TOTAL Remarks: ❑Copy to: - Cash Water Service o�-=' ' Check ) Money - Cashler Order CVWD-438 (11 /89) f - VALLEY VirlDE P IN1P!NG SERVICE ' 100. Sunrise Wa -i SY Suite 133 PALM SPRINGS, CA 92262 I. (619) 322.2400 - (619) 347-3545 "YOUR WASTE IS OUR PROBLEM-1 ' _ I I, . i 'I I• i - I- 4 i t