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9705-061 (SOTB)I 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 /23c+5cw li jI05t/9R -� f/��. Date �'•� 'Signature of Contractor,,, _ / -" �r `� j 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. (,.k 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. (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 yCode, I shall forthwith comply with4liose provision ! AJ Date: Applicant f l ` r t t Cfi: Lf '41,r - /W, JT �yP x. Warning. Fail re 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. Signature (Owner/Agent) ? !� �� Xffiate- J BUILDINGPERMIT PERMIT# CONTROL# q7415-06M 5112 DATE VALUATION t:3r_Zn.fi LOT TRACT JOB SITE ADDRESS 81-345 AVEiNUE 5 4 APN OWNER CONTRACTOR/DESIGNER/ENGINEER :1IHVI 'C,t,tI'll1i"4 E, AST VALLEYCONS'l'KUC ION 81r345AVENUIE '4 5,%80 AVE. ALVARADO 1,AQUINi'A CA 42253 LA.t-111N't'A ['A 92253 i t l� jSti•3•dR id 031.0 1 "ss i USE OF PERMIT !Sl ill.l.f(1Vt.i IIIIIIIIIIII�lIIIIIIIIIII 70 IE b! t_ORA(At fiQ04 ANO I(At 'It !RikCK oARSE V.K11CIN EHC(i 4'4:t1�1:4Y a�'4�.1�;:tiiltlit�'�AKt f 1.AN 1110% F f:fi 10 i-tR)0-43u-_319 S f 57 vt i 't ity!y 1'idl If 710N I -VP 101 _fHN)_JI9 tk)n 5241 tN► 110'17RICAL J I !i 101 UK) .1120-000 Vf, 5t► t1i't fl3ffvt.i a)ti: iti! titiii•�il ix'rtJ S.ti.{>t1 3 ft i J11i_>'"i'tr 1N f4+ 11N4II ► 10 1 -(XX) -2414)!!fl StJIVII )rl'AL t `t fNCI*R1 X-'1'tt )IN ANIS III -AN 0IF(`K $.IX? Ril L.f::;fi NINE PAID FEl's fit) (it) Et )'E AL PERN41T IloW S MIF N(AV s02.ttff RECEIPT DATE i BY DA E 1N INSPECTOR INSPECTION RECORD II11IIII1I1��II11IIIII11I 71 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 -lee— Final Final BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS 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 .Q �r �. - Final a 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: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SQ. FT. ® $ UNITS COLL. AREA 2ND FL. SQ. FT. YARD SPKLR SYSTEM POR. SQ. Ff. ® MOBILEHOME SVC. BAR SINK GAR. SO. FT. ® POWER OUTLET ROOF DRAINS CAR P. SQ. FT. DUCT WORK DRAINAGE PIPING WALL SQ. F'f. ' DRINKING FOUNTAIN. SQ FT ® I HEATING (FINAL) 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 GRADING cu. yd. plus x$ LAUNDRYTRAY AIR HANDLING UNIT CFM FRAMING �G 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 SQ. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID ® 1 Vi c SEWAGE DISPOSAL SQ.FT.GAR ® V.c HOUSE SEWER GAR. FIREWALL 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 OUND PLUMBIN UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANKH WIRING DUCT WORK ROCK STORAGE OUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEQUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM FINAL INSP. �" L INSP. (/ $ GRADING cu. yd. plus x$ =$ LUMBER GR. FRAMING �G ROOFING s REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL HING MESH ULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL :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 Root Deck Exhaust Fans O.K to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls° Party Wail 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 Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS 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 Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: 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 Q Exhaust Fans 0. K. to Wrap F.A.U. Framing Insulation Compressor Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath i Drywall - Int. Lath aC all— Final Final BLOCKWALL APPROVALS steel POOLS - SPAS Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS 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 r Final Utility Notice (Perm) �_ COMMENTS: