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PLBG (9609-004)51710 Avenida Madero 9609-004 M LICENSED CONTRACTOR DECLARATION I'Oeby affirm under penalty of perjury that I am licensed under provisions of C: apter 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 8 . 1 C-42 / 10/3097 Date (f Signature of Contractors- / y'1 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 Jssued.. My,,w,ofkers' compensation insurance Carrie(& pq, igy 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 Code, I s all f rthwith comply with those.provisioonns -bate: 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 insI5ection purposes. iSlgnature (Owner/Agent) --/ /'tyDate BUILDINGPERMIT PERMIT# CONTROL# 909.014 3926 DATE 9/ 3M VALUATION 11,'4110.00 LOT TRACT JOB SITE ADDRESS 51-710 AVENIDA MADERU APN 773-113-00: OWNER CONTRACTOR/DESIGNER/ENGINEER 1.0110 VI'Mortt I'Ci7NO SF-WER SHMVIC'L' 31710 AVENIDA MAUEKU 84033 CAHAZ.UN KI). I.A QUITI'A CA 02753 PALM DrSERT CS t)l261 46191346-2703 CB1.4 342 USE OF PERMIT 1'l,lai\1#ljNc3 t OYFIC (TINNEt." r 11.f1t 1'rcJIV I,?tN).tNr f 5 r r.tAtA'r'r3) COS r' i:Drt C'4NS1RIt1C 10N 1,5IN1.00 PIA AtHINOt Flu- sri' fIX 101 -ON-419401 $-%A 00 If L CONST'RUC110N AND PLAN CI1ECK $ 0.00 LESS PRE -1 AID ITES $0.00 Yr'AL r'i+ RMIT 1 cMS ryUK NOW '"01111 RECEIPT DATE BY DATE FINALED INSPECTOR 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 OX 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 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 Appliapces { 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: YtiniN- •'g • .. !.'- "!' fi'.sna,'t.-'_9 . _..a ISS.e2+m -,a-. _w—- d.1s ^ ' t _ s.'! i•+ tit .. . .: , - -.. _ .. :. - - , - - i •iy• COACHELLA VALLEY WATER DISTRICT CASH aer•cwr nvreu Received F oZO fc Address: 2W:--)7zP,/ C — Account No. Lnt S Service Address ❑ Meter(s) ❑ Service(s) ❑ Backflow(s) ❑ House Laterals) ❑ DetectorCheck(s) ❑ Meter Surcharge >"nitation Capacity Charge SS— ❑ W.S.B.F.C. ❑ Temporary Construction Meter ❑ Tum on Charge ❑ Uncollected Account - Name ❑ Inspection Fee - Tract - Fee - ❑ Plan Check Fees Water I Sewer - Tract - ❑ Bond Payment - A.D. - Bond Assmt. ❑ Customer Deposit ❑ Other Remarks: ❑Copy to: Cash l Check Money Order G.A. Code S TOTAL $ Cashler ` - i. CVYYD-atiNtfei):: ECONO SEW£R SERVICES P.O. BOX 192 47548 PALM DESERT, CALIFORNIA 92261 1/•A AI/_' A7A•f rnVIVC JCO-//VV J'1 V'C/7JRDEH " j DAT5;, CUSTOMER'S ORDER NO. PHO N MEC A MELPER STARTING DATE BILL TO ORDER TAKEN BY ADDRESS ' DAY WORK E) CONTRACT EXTRA IY s JOB NAME ND OCA WORK ORDERED BY JOB PHONE PTION OF WORK: PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1%% PER MONTH CHARGE AFTER 30 DAYS Signature PIl0a1Cf 258.2Inc GNI00 Nate 01071.. No one home ❑ Total amount due for above work: or I hereby acknowledge the satisfactory completion of the above described work Total billing to be mailed after completion of work 11110 .4-4 TOTAL MATERIALS TOTALLABOR NO STATEMENT WILL BE MAILED TAX !7E COMPL TED WORK ORDERED BY TOTALAMOUNT $ Signature PIl0a1Cf 258.2Inc GNI00 Nate 01071.. No one home ❑ Total amount due for above work: or I hereby acknowledge the satisfactory completion of the above described work Total billing to be mailed after completion of work 11110 .4-4 BUILDING PERMIT CONSTRUCTION ESTIMATE 1ST FL } ' SOFT. @ 2ND FL. SO. FT. @ POR. SQ. FT. GAR. SQ. FT. CAR P. SQ.FT. @ WALL SO. FT. @ SO. FT. @ ESTIMATED CONSTRUCTION VALUATION $ 1_7 NOTE: Not to be used as property tax valuation MECHANICAL FEES VENT SYSTEM LZrFAN ❑ EVAP. COOL 2 110OC DEPARTMENT OF BUILDING & SAFETY COUNTY OF RIVERSIDE , NO. ELECTRICAL FEES *f ' MOBILEHOME SVC. ti t POWER OUTLET SWIM POOL, PVT SWIM POOL. COMM SIGN FIELD OFFICE NO. PLUMBING FEES FURNACE ❑ UNIT ❑ WALL ❑ FLOOR SUSPENDED LAUNDRY TRAY BOILER L—J B.T.U. BAR SINK ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN UP NAL WATER PIPING FLOOR DRAIN WATER SOFTENER ,l WASHERIAUTOI bISHI O L.;I APPLIANCEY 0U ! GARBAGE DISPOSAL 5 FURNACE ❑ UNIT ❑ WALL ❑ FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM IDLE METER KITCHEN SINK V ABSORPTION SYSTEM 0 B.T.U. TEMP USE PERM SVC WATER CLOSET p COMPRESSOR 0 HP fj1 POLE, TEMP/PERM LAVATORY '00 HEATING SYSTEM 0111 FORCED ❑ GRAVITY 00 AMPERES SERV ENT tf BG { SFOWER l ;5-0 -SQ FT @ ¢ / BATH TUB 6-0, SQ FT @ ¢ WATER HEATER SQ FT RESID @ le f SEWAGE DISPOSAL SQ FT GARAGE @ 'h¢ HOUSE SEWER PERMIT FEE 0 TEMP ELEC SVC GAS PIPING MOBILE HOME PERMIT FEE Is PERMIT FEE y 400 PERMIT FEE 11 U 2 P R TOTAL FE S ion MOB. HM; FEE MICRO FEE MECH. FEE / DBL. PL. CK. FEE =' CONST. FEE DBL. ELECT. FEE '' y DBL. SMI FEE l FEE PLUMB. FEE DBL —'J F M A M.__., ..-..,,- A ? 5 O -W _ f5—. JO.BC ADDRESS .... ,_. .. ._. _. .__:. .... __.. _. . I SP NO '' 04J(N6 . 11 C c J_ t S r f e 74 USE OF PERMIT '.. i` rc ' d. F.C. _ 'i DATE - /t --7 PERMIT RIO. 1439 75 M H PERMIT FEE $ COMMUNITY Lel DST 1.6 JJUNITS I ► ROOMS VALUATION / 7 SUPP. TO PERMITOFFICE MICROFILM FEE COPIES $ LEGAL DESCRIPTION .57L5._,, — "'fot6 &9l { " c.0j ` MECHANICAL FEE DBL $ y SET BACK// LOT SIZE ZONE ( . 1 1 aF _ USE NO. J GRP TYPE ] CK BY F S GJ— R {G/ PLAN CHECK FEE $ BOND AMT. PLAN NO. PLAN CHECKER _ _ FINAL DATE INSPEC R ' CONSTRUCTION FEE DBL $ ` [p l t C! NAME OF CONST. LENDER BRANCH rr f1T e, OFFICE NO LENDER INVOLVED ELECTRICAL FEE DBL $ / ADDRESS CITY _ STAATT'E' SMI FEE $ ,i / 9 THIS PERMIT SHALL BECOME VOID IF WORK IS NOT COMMENCED WITHINgp DAYS. CESSA. TION'OF WORK FOR 120 DAYS SHALL ALSO CAUSE PERMIT TO BECOME VOID. 1 HEREBY AGREE THAT ALL WORK IN CONNECTION WITH THIS PERMIT WILL BE DONE IN AC. CORDANCE WITH THE LAWS OF RIVERSIDE COUNTY AND THE STATE OF CALIFORNIA, I ALSO AGREE TO CARRY COMPENSATION INSURANCE UPON MY EMPLOYEES. COMPLIANCE WITH THE LAWS OF THE STATE OF CALIFORNIA COVERING CONTRACTORS IS ALSO GUARANTEED. I HEREBY CERTIFY THAT THE INDIVIDUAL WHO PREPARED THE PLANS AND SPECIFICATIONS HAS DONE SO IN ACCORDANCE WITH SECTION 5541 Of THE BUSINESS AND PROFESSIONS CODE OF THE STATE OF CALIFORNIA, FEE $ PLUMBING FEE DBL $ ,3(} ®U TOTAL FEES $ / ;7 49 OWNER/AGENT'SSIGNATURE /'3 '66a 4 e -7 -Pe kq CONTRACTOR CASH ❑ CHECK . M.O. ❑ N.C. ❑ ADDRESS /,7 7W I vd v _ ADDRESS RECEIVED BY TREES REQUIRED 1 SEWAGE SYSTEM T LL P INFORMATION FORM 284 2081Rev 9731 Its CITY ZIP CODE -a CITY ZIP CODE TEL. NO. – TES. NO. LICENSE