11399 (PLBG)P.O. BOX 1504 N o . 1139.9
Building78-105 CALLE ESTADO t �,
Address 5`65 HerreraLAQUINTA,CALIFORNIA92253..'�-
Owner
David id & Patricia Keeley
Mailing BUILDING: TYPE CONST.OCC: GRP.
Address Selme
A.P. Number
City Zip Tel.
La Quinta 922.53 Legal Description
Contractor Project Description
Address `Saer Hook Up
City Zip Tel.:
State Lic. City
& Classif. Lic. # Sq. Ft. No. No. Dw.
Size Stories Units
Arch., Engr.,
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
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) of 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 I am exempt from the Contractor's License Law for the following .
reason: (Sec.. 7031.5,Business and Professions Code: Any city or county whichrequiresa
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) or
Division 3 of the Business and Professions Code, of 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 ($500).
I as owner of the property, or my employees with wages as their sole compensation, will
�O the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and .
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or Improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or Improve for Me purpose of sale.)
❑ I, as owner of the property, am.exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law -
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) -
❑ 1 am exempt under Sec. B. & P.C. for this reason
.
Date Owner V, r, fl ,. � �
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a'certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
I ❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the permit is for -one hundred dollars ($ 100) valuation
or less.) ,
I certify that in the performance of the 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,Cali(ornia.- i
Date c !? f caner � K V-0
NOTICE TO A PUCANTSafter making this Certificate of Exemp5�gqon you should become
subject to the Workers' Compensation provisions of the Labor Cdde, you must forthwith
comply with such provisions or this permit shall be deemed revoked. • . to
CONSTRUCTION LENDING AGENCY
1 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 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
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:
Estimated Valuation
100
PERMIT
AMOUNT
Plan. Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
a '
Electrical
Plumbing
3U —.U—(F—
US.M.I.
S.M.I.
Grading
Driveway Enc.
`
Infrastructure
TOTAL
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
COLL. AREA
2ND FL. SO. FT.
YARD SPKLR SYSTEM
BONDING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
SEWER'UR9E42�
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
FOUND. REINF.
DRAINAGE PIPING
CAR P. I SQ. FT.
HEATING (FINAL)
OTHER APPJEQUIP.
WALL SQ. FT. @
DRINKING FOUNTAIN.
SO FT ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FINAL INSP.
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.
SO. FT. ® c
BATH TUB
FIREPLACE
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1+/a c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ic
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
SEWER'UR9E42�
(j UGH 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.
$ Plus—x$—=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
.-0
REMARKS:
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION l-2
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESJINITIALS
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
f2
Received From: - 'J- Date: 74Z I— 7a2,
Address:E P'los10A c"4
Account No. Lot(s) is Tract 70
5'Y✓
Service Address G.A. Code
• Meter(s) $
• Service(s)
• Backflow(s)
• House Lateral(s)
• Detector Check(s)-
• Meter Surcharge
UllaWtation Capacity Charge In/
• 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
• Other
TOTAL
Remarks: WILL 46Z MY2: V1F!T1 7_10A]
'D COPY to:
Cash Water Service
Check i4z zvv/
Money < I ler
Order CVWD-43e (11/89)