9703-037 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License:#' Lic. Class Exp. Date
494257 L-29 6130196
Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
STATE FUND 71s1.5tft 96 .
(This section need not be. completed if the permit valuation is for $100.00 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 California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
'Pate: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject .to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
,,S gnature (Owner/Agent)
Date
T#
BUILDING PERMIT PERMI97CONTROL#
��3-037 4798
DATE .�%1 % VALUATION S1,7�0 00) LOT TRACT
ADDRESS 51-782 Cij�jt$Ii�GON JOB SITE
APN
OWNER CONTRACTOR / DESIGNER / ENGINEER
51.-782 OWLEGON 5216-17 AWNIDA VILLA
LA rA. IMA CA. 02253 LA QIANTA CA 922-5:3
lfi t 4}tic}�E-21:25
CHIN 1218
USE OF PERMIT
X1.00 LF
1f,9..1T%7•A rE0 COST OF C ONI S`fINJCTION I;Z50.00
PCIA-MiT FEE SUMMARY
C(J NB'1'I't6K Ttf_)N FC,8 101-1)00-_118-000 $54,(0)
KAN ( KT..ICK '$54,00
LESS t IKE.-1"AlD FEES x$0.00
'rpt., iwBi:9ii11i8"9 9+'4i;li+ti IgVE P>1O.iW %R�+S.i9fft
RECEIPT I DATE `—II BY I DATE FINALED I INSPECTOR
R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings -!
Main Drain
Bond BeamEZ
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING PP OVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
; •`: ": ':_ :: DEPARTMENT.OF BUILDING B SAFETY
N[A7 to v[NT. IT(
I
,;: .
fEf ort
HEADQUARTERS.
SPEC. IN P. EE UM I � OBL.
C_0UNTY OF RIVERSIDE
:.:.; =' CONSTRUCTION ESTIMATE
ELECTRICAL FEES
PLUMBING FEES
w15T,FL':
50. FT.
NO.
NO.
SO, FT:.
i%:�':,'''\:: I..i.�.
Urr I
50: F.T, • eo ' ' -
MOTOR 1 OR 1E55 H.P.
i
.�
SOFT.
MOTOR S OR LESS M.P.
'
R P.'�:
MOTOR 20 OR LESS H.P.
DRAINAGE PIPING
LL • . ,'
SO FT.
DRINKING FOUNTAIN 1
SO. FT. �..
iGAE
URINAL ;1
u1t OF rUILDlllr Alin '
K.W. uNiTS
WATER PIPING
'.EST11"TED"VALUATION. ;.` .5.:.
" I
FLOOR DRAIN
:`MECHANICAL -'f
WATER 56FTENER
VENT SYSTEM O FAN [] EVAP. COOL O HOOD
SIGN
WASHER (AUTO) (DISH)
APPLIANCE
K,W,
GARBAGE DISPOSAL i
FURNACE O UNIT O WALL O FLOOR 0 SUSPENDED
OWLETS
LAUNDRY TRAY
'AIR HANDLING UNIT CFM
FIXTURE OR SOCKET
KITCHEN SINK
GAS PIPE O NATURAL O t.P.G. O OU
GONS1. SERV. ENTRANCE
WATER CLOSET
COMPRESSOR HP
PM
LAVATORY
APPLIANCE VENT
AMPERES SERV. ENI.
SHOWER ;
ABSORPTION SYSTEM B.T.U.
SO. FT. @ Q
BATH IUB
INCINERATOR O DOMESTIC O INDUS. OR COMM-
10, Fl. @ 4
WATER HEATER
HEATING SYSTEM O FORCED O GRAVITY
$0. FT. RESID. @ 1 C
SEWAGE DISPOSAL
BOILER.. B.f.U.
SO. F1. GARAGE @%c
HOUSE SEWER
PERMIT FEE
BALANCE Or MIN. FEE
GAS PIPING
ILER ISSUANCE FEE • PERMIT FEE
PERA(II FEE
/ PERMIT FEE /1
. i .REIL R4� . i
6
N[A7 to v[NT. IT(
I
pl. CK fE[ CONST.
fEf ort
ELfC FEk oet
SPEC. IN P. EE UM I � OBL.
1
LOusaf
i%:�':,'''\:: I..i.�.
Urr I
Joe A094911.
owil
iGAE
u1t OF rUILDlllr Alin '
PLAN CHECK FEE
E
" I
f v ;
ch Rego or
corrUrl,r
r C
urea
v•Ltlq,Ow16'Tc
j
MECHANICAL FEE
s
/a U/,ti /¢
101STep-1
/
1
i
-Dot.
O
►
►
l[Oa{ ♦[1C■IR10w
♦Ctrli
Wt
I
CONSTRUCIION FEE
,107-5.4Ag,4 gtir= A. r re4 �
19
1 46:
rtAr CrfCAFr
10 ♦ . r
'
— 773 —19,V
ElECTRKAL FEE
at
raw0 1
roxo
Dar
►uw Fuc ♦ r,wt o•n
Iwvec,ur
s
PLUMBING FEE
TRAILER PERMIT
use or tortl■ucloo urot■
■■•rcw OFFIct
w LiNot r
Irvotvso
FSSUANC F FEE.1
1
1
Aaa■a1
cm
naw
FEE
ti
V b
TOTAL FEES �^
THIS PERMIT SHALL BECOME VOID IF'WfjPK IS 1401 COMMENCED WITHIN 60 DAYS. CES5A11ON
WORK
OF 1:011120 DAYS SPUIIt ALSO CAUSE PERNfi TO BE
I HEREBY AGREE THAT ALL WOr1Y. 11-4 CONNECIION THIS 11 W1ll BE DON ACCOR- )
CASH CHECK MO. N.G.
DANCLE WITH THF. 6%WS OF RIVERSIDE COUP;1V A HE ST OF CALIFORTJIA. 1 AGREE TO
CARRY COMPENS. TION ITvST.kANCE LIP
CARRY EM YEE.S, MANCE WITH 111E 1/. F II1E IE '
REC YED !IY SEWAGEYS
OF CAUFORNUt COVERING CONTRACTORS Ib A GUA TEED. I
1 HETtEPY E
CERTIFY 114AT THE INU1VTDu4l 1Hf PIANS ��%%P�ECIP I P+S T N[
SO 1N ACCORDANCE WIN SECK-N 5541+ THE B FEcip45 ST E I
CMIECIRNIA- .1
10 rOMMATION
X 00A
Aoa■
ML OW .4r
��
.����.rr��-` ..
.•
uatlls.jj
'!l ,,:•:I`r' G�" `
FORM 38&2a PEV. )401
it :1(-:�v': �.: %.(�..'::.l
i%:�':,'''\:: I..i.�.
rct .l�:..t•4'�L:�.�':•':C.'�' ..1. i�,TC'.:
'OPERA I iyu DATE WSPLCTOR 40. QPERAT9ON- D11TE INSPECTOR
'BUILDING'ApphbVALs
MECHANICAL APPROVALS
77'.7 7r 33
----
Venfilation System
'
Plenum
34 3 & Ducts
-35 Vurnace'Comparl.
;W`;:2k �)-5100
36
j oullah
Intel
0
37
'C i6buslion Air
'38
-06rnpressor
7 7.
39: App
-Fire Dc:mper
V
nni -3) % i
F 133.,j
LJ- -• 3
L iNFoRMATIC1.11
`j'j-.1q3 7
.14.
7- 1
7'
r
Water
ELECTRICAL APPROVALS font Pit L. lino
'!A. Pow., Polo 1 1
W.,
27 Conduit
28 Servict- Entranto
29 Wiring
30 Fixtures
31 Service
32 Final
S
SEWER DISPOSAL LOCATION
n- INSIbE n 66irsibE. TIK
iron` : �: T-�.�''- ....c�::' �' � J...:' . , •: `. "-- ., _ , . _ _ . ;� •. . .
i,fyj}'df• i .n.�tr i r•4 ji;, :.'.: L '•' "j - . ;.. i A QUI1IN8 PRMIT Dist.OH
KK5c
T!0!! TD: CONSTRriLT Pefmit No
t �:y Of: RU1L1DING AND SAIFlTT
E • �-�=`"'"•, } -" ' ' _ � CBUNTY ;OE •RI11�IW Di • _ - - '
w -E j ci l{i.'stiS'.f�,C � •.`.�.;y '"! •r.} �c�; , _ ' J ^ '.i :T .. _ :. - •. - 1 . r
1 =�i,~� }:;cPj :.Olvier ,• ` r. ,::: :•tett `Coritracto���^�RiF�tr+,- C4...cf� �,
e` r, rfl:�`u��' 2': :ti �f- .r •%• _ +.i �_ it
wee 'AddfOlS���• _
/�.ti,-.''i✓,r» ij,:.;���;`y"�'� `:L�'� E;,:�•..,_ :h,_: ;5.
Gty:'
:' =� • �`e �' ` IE{noi,;flie�und�a ne4f-Mraby oerlttjrand eckrpwiedpe that i&w the 'apppWittwi''fnd'aptee llmt It Curb and Guttif, amd
Pi4i 4iFd/oF,06*ittoii U iijAl' of JwAy is; nQuifid by the'Couiity 6t: Rlveiiide; the aivatside Cuaady Department of tlulidfrap arid. Satery
f@4ke;
Mid Wp'h hin• until avid ripoemenls love bier met. i arm its6 'awire lhit no work Is to be him the Couhty R/W
O ;lIthgW an' .enemii hri enl perfnll_
NIOW, tl+PefrJfoeit it i :iQrsed-!fiat I (.+e)'wi11 not ocavy aw pfoperlY and mill not cause said pr occupied unlll 1 I have
iomjrlEed vi(f!i all laws of Isi County of Rivessade and tha State of Callifomla•yovernhq geld
_ - - �j.
'SIGpAT1JRE QF OWNER AND/QR AG NT
AIspn:al ►r S660M ftolw'tlle fapowl." Oeytet..wt� Llatd,Mio+►
Mea Iw Okahwd Ptiw to Nae Unii�y of a Coadmil s Penn%
` / ��//�E Cl OF STRUCTURE
LOCATION OF JOB SINGLE FAMILY ❑ DUPLEX
/A LEGAL pESCR PTION OF PROPERTY �' " ,
APARTMENTS ❑ AGRiC. ❑
V .
COMMERCIAL ❑ INDUSTRIAL 0
.. • _". '` ~ ' . COIAMIJNITY / ALTERATIONS ❑
-,
N9 . --OF SUBMITTED, PLANS TYPE OF CONSTR CTION
Aff
sz F.:P11ING SPACES REQUIRED s NO, OF BUILDINGS NOW EXISTING
SETBACKS FRONT SIDE REAR.
• i •;+GRADING PERMIT REQUIRED.- YES [j NO t7
BACK=QgRg_INA FE ET- REQUIRED
PATE' L.� SIGNATURE OF LAND USE OFFICIAL
L.01
DEDICATION REQUIRED. YES ❑ NO ❑ NO. OF FEET
CURB AND GUTTER REQUIRED: YES ❑ NO ❑ STREET
THE ABOVE CONSTRUCTION? YES ❑ NO ❑
CAN CURB AND GUTTER FEASIBLY BE INSTALLED? YES Q NO O
b'
HAS AN ACCEPTABLE APPLICATION BEEN MADE FOR ENCROACHMENT PERMIT FOR DRIVEWAY AND STREET
OIMPROVEMENT? YES ❑ NO ❑
DATc _ SIGNATURE OF ROAD DEPT. OFFICIAL
SWIMMING POOLS PUBLIC
SEWAGE DISPOSAL
_ o FOOD ESTABLISHMENT
WATER POLLUTION _ ;:REMARKS
FLOOD CONTROL '
' AIR POLLUTION
Div OF NWY
i YOUR PROPERTY MAY BE SUBJECT TO
FLOOD.• RIVERSIDE COUNT7,ASWMgS
,NO RESPONSIBILITY-IN'EVENT'OF FL00a:
i
iPl-jvv. s116/bv 'V�IiilT,i::aROJ1D:' CAti'--•• Y—=Fif .:. • :�: ,• .;•. _ ';
,; �:•' , �-, gIPT:,• i►aI ' FIN k:='-'1VPLIC�1Nr
;."'•^.. ,.-,1 �•:., -•!•-:tn.e,•.. ,,N�:w'+"t, ..nre o'.,�..Ir•:... i. ...-.._ ,• v ..•V .•..n:. ;'r•: ...r__...:W-1.• '�:. - "•.-rh•.t..,