PLBG (9701-068)77125 Calle Madrid
9701-068
10122
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
JZ
.2 C36
Date" `' Signature of Contractor 6 /,LI
v
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.
2M_N1ty111,f.X4 ON 141111
(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 Califorpia, and agree the irl—thould become
subject to he workers' compensation provls70
lons of ' etlon 30 of the Labor
de, I s all fq hwith comply with th se p -ovlsipgns.
/Date: ` 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;7nd State laws relating to the building
construction, and hereby authorize representatives,6f this City to enter upon
the above-mentioned property for ins►%pu✓r% ses/ ,y . j
ignature (Owner/Agent) r //'/'./ Date V `VM
BUILDING PERMIT PERMIT# CONTROL#
701-068 4607
DATE 1&.9,7 VALUATION • LOT TRACT
JOB SITE
->l
ADDRESS 7'i1-9 CALLMAi RID
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
77125 CALLS MADRID
7&17 SVL i3OX
[.Jk , UItT1'A C 92153
VIC_ToRVILL.1? CA 4'22192
ftil"i12 i •t:141 CAI -q :><iI21
USE OF PERMIT
i i_,1.jA f Ii
WA i. hk f fD% t jik 01AN Q i i.w t
'r ALl,fAMON 3%11iiii LIS
STOFCONNSIMPUION
PEAM)Y VEE'tiUMINIARV
Jf r //o rrff q tl
f'f.[1N1HfM3 FEE 1V14WO-419-000
a
Q' ®
LESS PtIZE-PAI17 FIEFS
eoCY
. .!2 t 50
$0M
--y %r .t,O_f',tL PERM>i•I,' %'E 0111;,. NOW
Q44.
RECEIPT
BY
DATE FINALED
INSPECTOR
g.
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 Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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 •
Final
Utility Notice (Perm)
COMMENTS:
AAA Building 77-'125 Madrid
C&hf4abd
P.O. BOX 1504 C, No. 10122
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Owner
jacquel"e Montgomery
Mailing
Address Box 1023
City Zip Tel.
. LaQuinta 92253 564--6012
Contractor
Oviner/BuAder
City lZip
State Lic. City
& Classif. Lic. #
Arcn., tngr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 em 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.
_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 county which requires a
permit to construct, atter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to rile a signed statement that he is licensed pursuant 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 basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
❑ 1, 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, Buisness and
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,
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
of proving that he did not bulld or Improve for the purpose of sale.)
O 1, 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 propertywhobuilds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
O 1 am exempt under Sec. B. & P.C. for this reason
Date Ownte:e`.ar/tf�.N 0-
7,
4 r'i
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.
CERTIFICATE OF EXEMPTION FROM.
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 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.4 — -�
Date Owner •: cl ,sy f..f f'..r�' „ �e.r �' .-;,e_f, , .�- .. - ' -
NOTICE TO APPLICANT: AaRer making this Certificate of Exemption you should become
subject to the Workers' Compensation 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 properly filled out, signed and validated, and is subject to
expiration it 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, Slate, Zip
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
Legal Description
Project Description
SEWER HOOK UP
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ 'Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing 30.00
S. M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL 30.00
REMARKS
_ ..+7A`.�'�.,r!".....AG1 �.t►3f�,.1�'t�t1-�1f,.; .nom: 3. t?
s 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
1ST FL. SO. FT. ® $
2ND FL. SO. FT.
FOR. SO. FT. ®
GAR. SO. FT. ®
CARP. SO. FT.
WALL SO. FT. ®
SO. FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
1r -
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
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
SHOWE_ R
BOILER. B.T.U.
SO. FT. ®c
BATH TUB
BOND BEAM
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/. c
SEWAGE DISPOSAL
LUMBER GR.
SO.FT.GAR ® 3/ac
HOUSE SEWER
FINAL INSP.
ROOFING
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
bSEWER Ad
R UGH WIRING.
DUCT WORK
ROCKSTORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION jQ !
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
/1
Account No. dC7 `
Lots)
Service Address _71'—
❑ Meter(s)'
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ Detector Check (s)
❑ Meter urcharge
anitation Capacity Charge _Q/
❑ W.S.B.F.C.
❑ Temporary Construction Meter
'❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
11 Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
'
❑ Customer Deposit
❑ Other
Remarks:
Tract "V' Lka an
G.A. Code
TOTAL