15346 (PLBG)/4
Building
Address 51-885 ave • Herrera
P.O. BOX 1504
78-495 CALLE TAMPICO
LA OUINTA, CALIFORNIA 92253
_.„„.' Daryl Lezier I
Address 9500 Ave. Foal Oso N.E.
City Zip Tel.
Alburquerque t 8 ;11
Alms " Underground Const.
38703 Vista £fir
CityZip Tel
cathedral Cita , CIA 92234 324—i9il
State Lic. C--42 482180City 769
&Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
f City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
hereby� a�ffirm that I am licensed under provisions of Chapter 9 (commencing with Section
) oMigision.3 of the Business and Professiohs" Code, and my license is in full force and
e''iia lect�,� t r� Y
SIGNATUREDATE
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, 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 rive 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, Suisness 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 o/ completion, the owner -builder will have the burden
of proving that he did not build or knprove 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 contractor(s) Qcensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certifiedreopy thereof..(Sec. 3800, Labor Code.)
Policy_4of W S f:. i t Companyi f :, ri^ I' .. f
O0Copy is filed with the city, ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed N the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of th? 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.
. i
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 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. 15346
BUILDING: TYPE CONST. .00C. GRP.
A.P. Number
Legal Descril
Description Sewer Connect
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
sti mated Valuation $1,275.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const. -
Mech. -
Electrical
Plumbing
30.00
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
FINE
�� ' I INSPECTOR
Issued by: 1 Dateiq� Permit
Validated bv:
Validation:.r�'f��—"�
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBINU FEES
1ST FL. S0. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
ROUGH PLUMB..
YARD SPKLR SYSTEM
2ND FL. SO. FT. @
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
METER LOOP
HEATING (FINAL)
DRAINAGE PIPING
CAR P. SO. FT. ®
GAS (FINAL)
WALL SO. FT.
DRINKING FOUNTAIN
SO. FT. ®
WATER HEATER
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
GRADING
cu. yd.
$ plus x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
ROOFING
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, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ® c
BATH TUB
SPARK ARRESTOR
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1+/a c
SEWAGE DISPOSAL
LATHING
SO.FT.GAR ® 3/ac
HOUSE SEWER
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
SEWE R S£F.i
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.
777
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 SIGNATURES/INITIALS
GARDEN WALL FINAL
'
COACHELLA VALLEY WATER DISTRICT
6255
CASH RECEIPT DETAIL
,
Received Fro m:
v' +
Date:
Address: s�
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ll
('
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Account Nof/
Lots! v
Tract
n;:•.!� /
Service Address �y�/ — _. � _ . � _ ��.D Fi^ '•(�'t.-
G.A. Code
❑ Meter(s)
S
O Service(s)
O Backflow(s)
❑ House Lateral(s)
O DetectorCheck(s)
❑ Meter Surcharge
-
"Sanllation Capacity Charge
�/J'�
/ T.25.
O W.S.B.F.C.
O Temporary Construction Meter
O Tum on Charge
❑ Uncollected Account - Name
O Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer
-
Tract -
O Bond Payment - A.D. -
Bond
Assmt.
O Customer Deposit
O Other
TOTAL
S
Remarks:
❑Copy to:
Cash
Check
N
Water Service
/fes
Cashier/
Money
Order
-
CVWD-438(11189)
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SANCO ~}
PUMPING SERVICE ( 2502 Morongo Trail
Palm Springs, CA 92264 N2 10068
(619)327-8859
SOLD TO
S ESMAN
TERMS
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STREETNCO/.
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CITY
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CITY STATE ZIP
CUSTOMER ORDER
S ESMAN
TERMS
DATE
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PAYMENT DUE -UPON RECEIPT