11066 (PLBG)4
7&10P.O. BOX 1 W45 CALLS ESTADO If N O. 11066 1 ®6 6
Building 54-035 Eisenhower Tar. LA �"}�
Owner
Rachelle PomelGe. eve le
& Albert � - "isl "�' BUILDING: TYPE CONST. OCC: GRP.
Mailing
Address Swae as above
IA -P. Number
City Zip Tel.
La Quinta 32253
Contractor
0-mer/Builder
ity lZip
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
I Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Cade, and my license is in full farce and
effect.
SIGNATURE. DATE
OWNER -BUILDER DECLARATION +
I hereby affirm that I am exempt from the Contractors License Law for the following
reason:,(Sec. 7031.5,Business and Professions Code: Any city or.counly, which rewires a
permit to construct, atter, improve, demolish, or repair any structure, prior to its ssuarioe also
requires the applicant for such Permit to file a signed statement that he is licensed pursuard 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 Osis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a peroR
subjects'the applicant to a civil penally of not more than five hundred dollars.(E500).
X& 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, Bwsress and
Professions Code: The Contractor's License Law_ does not apply to an owner of properly who
builds or improves thereon and Who does such work himself or through his own errpbyeim
provided that'such improvements are not intended or offered for sale. fl, however, the bu4&g
orImprovement is sold within one year of completion, the owner -budder wig 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 contrails for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
i
O 1 am exempt under Sec. B. & P.C. for this reason
Date OwneS�'•.
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurancei or a certified copy. thereof. (Sec. 3800, Labor Code.)
Policy No. Company
O 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) valiatimn
or less.)
I certify that in the performance of thg work,for which this permit is issued, I shall not
employ any person in any manner soas to bedome subject to the Workers' Compensation
Laws of California.
Date Owner f ,/„� �' �� ter•- f,, �,f-`.,r _ +,`J'
NOTICE TO APPLICANT: lfa afte&makfng this,Certifrcate of Exemption you drd
�shd became
subject to the WorkerVCmpensation 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 property 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
Legal Description
Project Description
Sewer Hook Up
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ -Demolition ❑
Estimated Valuation
•
pryr�
500.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing-
30.00
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
IST FL. SO. FT. ® $
UNITS
SLAB GRADE
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
POR. SQ. FT. ®
MOBILEHOMESVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
FOUND. REINF.
GAS (ROUGH)
DRAINAGE PIPING
CAR P. SQ. FT.
OTHER APP./EQUIP.
REINF. STEEL
WALL SQ. FT.
TEMP. POLE
DRINKING FOUNTAIN,
SO FT ®
GROUT
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
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
REMARKS:
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1Vi c
SEWAGE DISPOSAL
SO.FT.GAR ® 3Ac
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 SEPTIC TANK
ROUGH WIRING.
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
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 INS
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
Received
Address:
AccountIN
Service Ai
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge L
�Sanitation Capacity Charge '
S
❑ 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
COACHELLA VALLEY WATER DISTRICT
CASH RFrFIPT DETAIL
N! ;lege
Remarks:
t-
//�/
0 COPY to:
Cash
Check
_
Money
Order
il-- .. ,-i
Water Service .le -�
Cashier
CVWD-438 (11189)