10853 (PLBG)4
` P.O. BOX1504 No. 10853
Building 78-105 CALLE ESTADO
Address 46-8a0 HIGHLAND PALMS LA QUINTA, CALIFORNIA 92253
Owner
Mailing =KENNrTH ODELISI BUILDING: TYPE CONST. OCC.GRP.
Address SAHE A.P. Number
City Zip Tel.
LA QUINTA 92253 779- Description
Contractor Project Description SEWER HOOKUP
A.D.O. CONSTRUCTION
Address
1035 BONIUE BEACTI
City lZip Tel.
LOS ANCELLS 1 90023 310-612-53E3
State Lic. City
& Classif. 336137 Lic. # Sq. Ft. No. No. Dw-
Arch., Engr., Size Stories Units
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.
s)nNAgE _ oAl E
OWNER -BUILDER DECLARATION Estimated Valuation r
I hereby affirm that I am exempt from the Contractor's License Law for the Following Y 1 s 10 0
reason: (Sec. 7031.5,Business and Profassons Code: Any city or county which raquue.s a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also AMOUNT
requires the applicant for such permit to rile a signed statement that he is licensed pursuant to PERMIT
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 Plan Chk. Dep-
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 Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Bussness and COr1St.
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, Mech.
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 Electrical
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- Plumbing
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 S.M.I.
such projects with a contraclor(s) licensed pursuant to the Contractor's License Law.)
Grading
❑ I am exempt under Sec. B. & P.C. for this reason
Driveway Enc.
Date Owner Infrastructure
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
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
TOTAL Y 3yJ• J
CERTIFICATE OF EXEMPTION FROM REMARKS
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 thg 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. 11, niter making this Cerritknfe of Exwnption you should become ZONE: BY:
subject to the Workers' Compensation provisions or the Labor code. you must forthwith Minimum Setback Distances:
comply with such provisions or this parmll shall be doomed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) Side Setback from Property Line
Lender's Name _
Lender's Address.— 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 stale 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.
mentloned property for Inspection purposes. Validated by:
Signature of applicarrL_ ,Date
Mailing Address Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO.
ELECTRICAL FEES
NO.
PLUMBING FEES
1ST FL. SO. FT. ®
2ND FL. SQ. FT. 0
FOR. SO. FT. ®
GAR. SQ. FT. ®
CAR P. SQ. FT. ®
WALL SQ. FT.
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION
$
UNITS
YARD SPKLR SYSTEM
MOBILEHOME SVC.
BAR SINK
POWER OUTLET
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
$
WATER PIPING
NOTE: Not to be used as property tax valuation
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
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DEL
TOTAL FEES
MICRO FEE
MECH.FEE
PLCK.FEE CONST. FEE
!ELLECT.FEE
SMI FEE
PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING R AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER 9A1*PW&-'M*C
i
A UGH WIRING
DUCTWORK
HUUKSIUHAUF
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 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 SIG NATURES11MITI AL5
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT _ �y
CASH RECEIPT DETAIL
�
Received From: / T ,! Date: — 7 r
Address: Z4G "�rEt7Cl ��f� �r�Jt fC'WZ� b/l _ 77 eQt1 1'��7_A CA. 2��— ��
Account No r� / Lot(s) / V Troy{ Dom-1 17
Service Address 46-3-- 960_ _N! po i,, n7JI�
❑ Meter(s)
❑ Service(s)
C1 Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s).
❑ Meter Surcharge x
anitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
El Plan Check Fees Water I Sewer -
Tract -
El Bond Payment - A.D. - Bond
❑ Customer Deposit
❑ Other
Remarks:
❑Copy to:
Cash
Check
Money
Order
101
G.A. Code
S2G
TOTAL $
Water Service
�i
Cashier_
CVWD-43e (11189)