15496 (PLBG)P.O. BOX 1504 No. 15496
Building78-495 CALLE TAMPICO
Address U-Niesta LA QUINTA, CALIFORNIA 92253
Owner Robert C. Edwaeds -
BUILDING: TYPE CONST. OCC. GRP.
Mailing gM�
Address
City Zip Tel.
La Quanta, CA 92253
Contractor
Bob EdwArds
Address
81-333 Pelos Place
City Zip Tel.:
Indio,, CA 1 93201 775-7933
State Lic.., City
& Classif. B 684857 Lic. # 342 -
Arch., Engr.,
Designer
Address Tel.
City IZip I State
Lic. #
�. LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed-undt;r{provisions of Chapler 9 (commencing with Section
JJ000) of Division 3 of the Business and Professions Code,apd my license is in full force and
effect. y /<" I � sf
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 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 penally 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 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.)
b'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 Contractors License Law.)
D 1 am exempt under Sec. B. & P.C. for this reason
Date 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 �Noo' / Company
[Cdpy is filed with the clty; 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 ($100) valuation
or less.)
I certify that in the performance of thq 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
Dale Owner
NOTICE TO APPLICANT. H, after making this Certificate or 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 s 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
P. Number
Description
roject Description
Sewer Connect::
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation $1,000.00
PERMII T
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
-
Mech.
Electrical
Plumbing
38-.00
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
30.00
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--Pelait
Validated by:
Ra/)
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBIW'j FEES
1ST FL. SO. FT. ® $
UNITS
'
2ND FL. SO. FT. ®
BONDING
YARD SPKLR SYSTEM •�
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
ROUGH WIRING
DUCT WORK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
METER LOOP
HEATING (FINAL)
DRAINAGE PIPING
CAR P. I SO. FT.
GAS (FINAL)
TEMP. POLE
WALL SO. FT.
DRINKING FOUNTAIN
SO. FT. ®
SERVICE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
BOND BEAM
WATER PIPING
NOTE: Not to be used as property tax valuation
GRADING
cu. yd.
$ plus x$
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
REMARKS:
LAUNDRY TRAY
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 ® 1'A c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
MESH
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 OR S C
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIONATURESJINITIALS
GARDEN WALL FINAL
Received From:
Address:
Account No '
Service Address7S' /-_0 1�1 '
❑ Meter(s)
❑ Service(s) -
❑ Backflow(s)
House Lateral (a)
❑ Detec,orCheck(s)
❑ Meier Surcharge
Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Tum on Charge
❑ Uncollected Account - Name
❑ Inspection Fee -Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond_
Assmt
❑ Customer Deposit
❑ Other
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Lot(s)
Ks 54't21
Tract
G.A. Code
S
v'Z/Oa•U
15�s�(-j
TOTAL
Remarks:
❑Copy to:
Cash. _
Water Service
Check
_)
G/
Money
!,
O
Cashler
_
0rder
�/
r
CVWD-438 (11189)