13216 (PLBG)T4tyl ot � 4 a”
Building
Address 52-805805 Villa
09wn Aodriquez
Address . Same
City Zip Tel.
Indio, .CA 1 92201
RVS Plumbing/R. V. Stevenson
4TTO Velardo Drive
P.O. BOX 1504
78-105 CALLS ESTADO
LA QUINTA, CALIFORNIA 92253
V am Desert, 7ip,62260 Tel.:341' -9224
State Lic. City
& Classif. _ 602396 Lic. #. 2328
Arch:, Engr., -
Designer
Address Tel.
ity Zip State
Lic. #
1' ! LICENSED CONTRACTOR'S DECLARATION
I he affirm tt�at11.3m IcensetNg0er _,,jsps�of Chapter 9 (commencing with Section
000) of Divisloo_nr��7}',f tt1F1/€/dative§1ayn�d.'P ofessiori -Code, and my license is in full force and
ffecL_-%� -/YAH/ / �rfY� )t u{ f 2+,%, �i.
OWNER -BUILDER DECLARATION
1 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
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).
❑ 1, 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 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.)
❑ 1, 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. R 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. 0 Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed-if-the,permit is for one hu tired dollars ($100) valuation
or less.), 4; /C77"'
I certify that in the performance of hp work for which thjsapermit is issued, I shall not
employ any person in any manner so as•to,tiecome liJ'e t to-the'Wor ers' Compensation
Laws'of California. o. �_ T
Date '" `7 `O wnor 1 r9U
NOTICE TO APPLICANT If,„ -.after ma ing hiserti rcaterg Exemption ydul 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 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. 13216
11LDING: TYPE CONST. OCC: GRP.
P. Number
Legal Description
Project Description Sewer Connect
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation $1,1000.00
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.' `
Electrical .,
Plumbing . 01 V
.S.M.I. '
Grading
Driveway Enc.
Infrastructure
TOTAL v
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
.JEES
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
SEWER
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APP.IEQUIP.
DRAINAGE PIPING
CAR P. SQ. FT.
TEMP. POLE
WALL SQ. FT.
GROUT
DRINKING FOUNTAIN
SQ FT ®
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
_$
FLOOR DRAIN z
MECHANICAL FEES
FRAMING
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
REMARKS:
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, TEM/PERM
LAVATORY,
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
MESH
SQ.FT.GAR ® 3/ac
HOUSE SEWER
INSULATIONISOUND
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
SEWER
OUGH 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 ®'L
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT
-
r�
7 `7Received
.CASH RECEIPT DETAILz
(��Li
4
From`—'(
,lj2.-C(!�'7f
ate
O
-Address:
(s
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1n
Tracp- __ l
AGI CC.
Account No.
:Lot
`
♦ Service Address )
LP. C
ct :
t
G.A. Code
•' �
❑ Meter(s)
..
$
.. � ,
' ❑ Servlce(s)
❑ .Backflow(s)
❑. House Lateral(s)
r
❑ Detector Check(s)
❑ Meter Surcharge
, . ..
Sanitation Capacity Charge
❑ W.S.B.F.C.
. ❑ Temporary Construction Meter
❑ Turn on Charge
,
❑ Uncollected Account -Name
O Inspection Fee - Tract -
• Fees
�
•
❑ -Plan Check Fees Water I Sewer
y Tract -
s
CL Bond Payment - A.D. - Bond -
Assmt:
❑ Customer Deposit
❑',Other
TOTAL
Remarks:
❑Copy to:
V
_
CashWater
Check
•
Service
`•
Cashier
Money
-
Order
_
C -438(11189)