9610-036 (AR) LICENSED CONTRACTOR DECLARATION PERMIT# CONTROL#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 9611-016 4290
F' Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE �� 7m, VALUATION ��..�!#rb c!#(I LOT TRACT
CV W Professionals Code,and my License is in full force and effect.
C:) License# Lic.Class Exp.DateJOB SITE„,j
d H 1501.02 t I } l)(317!:1$ ADDRESS +gni•-159 ANIir
TPl UIt, st1 APN 769-274-026
OvDate lzeSignature of ContrBcto ,�� OWNER CONTRACTOR/DESIGNER/ENGINEER
P: OWNER-BUILDER DECLARATION KMrl`tI�4 t��'11?`JDA REXSEs E�F;1VF1 RI-E 41s"G,ENV 11A1,,C0N"I'
_J 0T
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 910209 AVENUE_54) 90209 AVENUE 0
~ U) License Law for the following reason: 1FdjAC)CA, 1,A t,LlFalNWT A {7A 92251
Z_ ( ) I, as owner of the property, or my employees with wages as their sole %4-16RO i�1n)772- 12S f:[tf.� 3{1 3
compensation,will do the work, and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals Kh'NI01.NfAAL A00iTiuN
Code).
() I am exempt under Section B&P.C.for this reason ;it t?-.”#t!!!t{iii►Alt!.l t�t:)7';�f>f.>#1'iE1"N't't t#N4;157'1Nf3 2�U0 SQtJAt#f3 FCKYI't10M WITH
N Date Signature of Owner AI)!)f`Clt7NAl. Orl'FjtIOR i Pittt)I?i{l,iN(1.
ON
a Q WORKER'S COMPENSATION DECLARATION
QZ I hereby affirm under penalty of perjury one of the following declarations: t'ltAt;t' ►Nylgct�c"I'{c.+lv ',I+it.W SFS
FZ p O 1 have and will maintain a certificate of consent to self-insure for workers' 't'1t,! I,250.06 SI
X w compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers'compensation insurance,as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier 1 RI!A1tJNT IN13frANI) Policy No. Wle•/.t:5t,+,192-1) ENTIN o-*;FEA)COST 0F C'0tii 'R1Xt:`1*K)iN 1301655.00
oD 5
0 PERN1113'FEY,SUMMARY
J (This section need not be completed if the permit valuation is for$100.00 or less). It 1-It-04 vi.- 11)t-tlft(1•.118-(N1<) %74A tttt
( ) I certify that in the performance of the work for which this permit is issued, IIt.AN C 11Ii-7V FIN.- 101.000- 139-:314 $657.'KT
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become !'1'•f?.1it%t't7:sIT _$".t». fi
subject to the workers' compensation provisions of Section 3700 of the Labor N1F e,:#JANR�A1.t l F: 1t}! E3t}Q•421 U0U F t7.iu
3 Code, I shall forthwith comply with t ose •rovisio s. ! V,:i`t,2 WIND I;W? 1{11-i1{It!-:1:?t1=11(}11 'F tills iH?
Date: g07Z Applicant , a, sr t ti•, t; 101 000 40000 r
Warning: Failure to secure Workers'Compensation co erage is unlawful and 14t;Ivt.1 h-h i't If+N t,10: RE-W) jtfi-t)ttit-;7i-tlfp4l At�+.1)/
shall subject an employer to criminal penalties and civil fines up to$100,000,in i mAl nNo+t 1441 101^f 0114 1.10.9) '4020 1")
addition to the cost of compensation,damages as provided for in Section 3706 W'r IN!rt 1111(( It't!l,.�r`f .`t- ltriEit{; 70I.flfNl•',S+•lltltt V-6 44
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 i - Q 5;111,-.`I(�rAI +''L N',3 111tJ(--110 Nr:t�ND PLAN N C;!i�;t'<`l.'.. $2,00.141
any permit issued as a result of this applicaton agrees to,&shall, indemnify I ,--�_ U LESS tPI2.�i_F'AID FFR -�,2503K)
& hold harmless the City of La Quinta, its officers, agents and employees. I�
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 NOV-07 1996 1"I°:�I P*F'�tM1TE�'I+;EN1l(1ii11�NfI*Af
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 f
' correct. I agree to comply with all City, and State laws relating to the building Sy IIIIIIIIIIIII�IIIIIIIIIII 52
construction, and hereby authorize representatives of this City to enter upon IE
the above-mentioned property for inspection purposes.
RECEIPT DATE BY DTE FINALED INSPECT
Vsignature (Owner/Agent) •' t ' l /! Date ,-7 1 d
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. Griffis
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Pibg.Test
Final I - Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines Neater 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
COMMENTS:
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)
AATY C;,4A QUINTA
f4or� `� BUIL ING &SAFETY DEPARTMENT
' I' 777-7012
' INSPECTION REQUEST LINE
' " 777-7153
,wner KEITH REESE
ontractor KEITH +,ESE, G.C.
armit Number 9610.036
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
)B ADDRESS 80-159 AVENI!E 50
2100 S.F RESIDENT 41 ADDITION PLUS
INTERIOR REMODELING
TYPE OF INSPECTION DATE INSP.
i IIJUATION&139TUACK
.OTING STEEL
AIN GROUND SYSTEM
MOUND PLUMBING
tE-GUNITE
) NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN I NED
jNCRETE SLAB
,ISTS&GIRDERS
ECTRICAL GROUND WORK
NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
)UGH ELECTRIC
)UGH PLUMBING
)UGH GAS&GAS TEST —G�2—
:ATI NG&VENT-A/C c —
Ii I'1 ACF
,OF 70�. -
)ND BEA
K. TO WRAP
,OUT ❑ 4' ❑ 8'
.AMING
3ULATION 6T .
,E-ROOF
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
XWALL INTERIOR
TERIOR LATH
)OL PRE PLASTER
IOL FENCE&GATE
vVER SEPTIC TANK
- FINALS
.ECTRICAL (J
_UMBING
JAL GAS TEST
'.ATI NG-A/C
)USE NUMBERS `. '
.B COMPLETED I4'
.MP POWER
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
�90 TURN ON UTILITIES OR OCCUPY BUILDING
IIIIIIIIIIIIIIIIIIIIIIIII 53
IE
P.O. BOX 1504 N o. 12912
Building 80-155 Ave. 50 78-105 CALLE ESTADO
Address LA QUINTA,CALIFORNIA 92253
Owner Helita Forester
Mailing ���
BUILDING: TYPE CONST. OCC:GRP.
Address
A.P. Number
City Zip Tel.
Legal Description
Cont ract'.°L1E'l��tl� Electric '+ Project Description Q�t electric 13�'1""� .�E
Addrell—M Joni Drive
City Zip Tela
Palm Beser � X22& 346--832
State sit. CitC-10 252580 Lic.#
&Classif. Sq. Ft. No. No. Dw.
Arch., Engr., Size Stories Units
Designer New ❑ Add ❑ Alter ❑ Repair❑ -Demolition ❑
Address Tel.
City i f Zip State
Lic.#
i
t LICENSED dONTRACTOR'S DECLARATION
I hereby affirm,that%I am licensed t�der provisions of Chapter 9(commencing with Section
7000)of Divi§ion 3 f the Business a d Professions Code,and my license is in full force and
e6fect. � � „ &�,/
SIGNATURE- @ DATE '
OWNER-BUILDER DECLARATION Estimated Valuation
I hereby affirm that I am exempt from the Contractor's License Law for the following $100.00 0.00
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 file a signed statement that he is licensed pursuant to PERMIT AMOUNT
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 five hundred dollars($500). .
O 1,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,Buisness and Const. l �{3
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.) 18.50
O 1,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.1.
such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
Grading
❑ 1 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
py is filed with the city. ❑Certified copy is hereby furnished.
TOTAL 33.50
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: If, after making this Certificate of Exemption you should become ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances:
comply with such provisions or this permit shall be deemed 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 INSP OR
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: Perit
I agree to comply with all city and county ordinances and state laws relating to building FEB
construction, and hereby authorize representatives of this city to enter the above `{�
mentioned property for inspection purposes. Validated by:
Signature of applicant— —Date—
Mailing
1
Mailing Address Validation: A
City, State, Zip
r
Ill 1
CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES
IST FL. SO.FT.® $ UNITS
' YARD SPKLR SYSTEM
2ND FL. SO.FT.p
MOBILEHOME SVC. BAR SINK
i POR. SO.FT.
POWER OUTLET ROOF DRAINS
GAR. SO.FT.®
CAR P. SO.FT.@
DRAINAGE PIPING
WALL SO.FT.® DRINKING FOUNTAIN
� SO.FT.@
URINAL
ESTIMATED CONSTRUCTION VALUATION $ 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 LAUNDRYTRAY
f AIR HANDLING UNIT CFM KITCHEN SINK
ABSORPTION SYSTEM B.T.U. TEMP USE PERMIT SVC WATER CLOSET
COMPRESSOR HP POLE,TEM/PERM LAVATORY
i HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER
BOILER B.T.U. SO.FT.®c BATH TUB
I SO.FT.®c WATER HEATER
MAX.HEATER OUTPUT,B.T.U. S0.FT.RESID®1 Va c SEWAGE DISPOSAL
SO.FT.GAR® 3/ac HOUSE SEWER
GAS PIPING
E 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
tfF[ 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.IEOUIP.
REINF.STEEL GAS(FINAL) TEMP.POLE
GROUT WATER HEATER SERVICE FINAL INSP.
s
BOND BEAM WATER SYSTEM
GRADING
r
LUMBER GR. FI L INSP cu.yd.
FRAMING FINAL INSP. $ plus x$ =$
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 SIGNATURESIINITIALS
GARDEN WALL FINAL