14861 (PLBG)4 Qum&
f
P.O. BOX 1504
Buildin 52-162 'Eisenhower LA pUINTA, CALIFORNIA 978-495 CALLE P253
Address
Owner
Julian Fernandez
Mailing
Address
City
Contractor
{3w';ta er! builder
..Address.
Tel.:
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
�tsae
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 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).
O 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.)
❑ 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) (lcensed pursuant to the Contractor's License Law.) -
❑ 1 am exempt under Sec B. & P.C. for this reason
i
i
Date Owner
I
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
I 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 ($100) valuation
or less.) '
i 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 California
Date Owner
No. 14861
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number
Legal Description
Project Description Sever Hook Up
Sq. Ft. No. ,
Size- Stories
New ❑ Add ❑ Alter ❑
Estimated Valuation
I
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical -
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
J
No. Dw.
Units
Repair ❑ Demolition ❑
AMOUNT
$30.00
t`
$30.00
NOTICE TO APPLICANT. N, after making this Certificate of Exemption you should become
'the
ZONE:
BY:
subject to Workers' Compensation provisions of the Labor Code, you must forthwith
Distances:
comply with such provisions or this permit shall be deemed revoked. -
Minimum Setback
, '
Front Setback from Center Line
Rear Setback from Rear Prop. Line
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND
Side Street Setback from Center Line
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES. UP TO.ONE ••
• HUNDRED THOUSAND DOLLARS ($/00,000), IN ADDITION TO THE COST OF COMPENSATION,
Side Setback from Property Line
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
'
FINAL DATE
INSPECTOR
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.
Issued by:
Date Permit
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-. '
Q
mentioned property for inspection purposes.
Validated by:
Signature of applicant 'Date
Mailing Address
Validation.
I
City, State, ZipMAK
1.0 IZI
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMB!EES
IST FL. SQ. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT.
FORMS
SEWER OR ! 5
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CARP. SQ. FT. @
FINAL INSP.
WALL SQ. FT. ®
WATER SYSTEM
DRINKING FOUNTAIN
GRADING
cu. yd.
$ plus x$
_$
URINAL
SQ. FT. ®
FRAMING
INSP.
��
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
REMARKS:
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
SPARK ARRESTOR
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
INSULATIONISOUND
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/4c
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 OR ! 5
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$
LUMBER GR.
,� n �y
/!sW-M'4��0xr ��l/ AL INSP.
!/��°�
/'✓FINAL
FRAMING
INSP.
��
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESlINITIALS
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT
_
r
A) A
Tmef
TOTAL
Remarks:
OCOPY to: 01)
Cash C
Water Service
-Check
MoneyCaShfAr
Order CVWD-438 (11189)