PLBG (0308-376)53830 Avenida Madero
0308-376
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
Date 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:
x.•( ) .,,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). • I1
` ( ) I am exempt under Section B&P.C. for this reason
Date
"_ "tr ESignature 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 1,certify that in the performance of the work for which this permit is issued,
I sl all 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.
Date: f Applicant
WarningFailure .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) r ; ' Date
J
t+ - I t
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
COW- /2(K SMOG
JOB SITEAPN
ADDRESS 53 -WO AVETIMA MS O(4p,
,t3
c
w - .
1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
VICTOR IT, G AMA.
O rV.E - Buff.S? i2
53-830AVENDAMAIASO
1AQUINTA C.A 92253
USE OF PERMIT
PLUMIDDIG
401, Ir. CYVERHEAD t?AS UNP, FO'OR.;F'11:O:RAVE RAWOR
r,
'VALUATION 150.00 LS
1GA7.E. 4YJ'«C AXN.<.1 1. 017 OF COY.74'1 .LtUC33,027
.150.00
Nit',R:@t%I r FEE VMMARY
PLUMBING "IF,
y
FS0 2 2003
CITY Orr! `•.A QUINTA
FINAh-L
:? DEPT.
SUa340'.lAt.. C:OUSIMUC 110Al.' AND Pt AstT CIMCK
$19.50
XMIS P. -PAM k i3
$0100
RECEIPT
DATE r
BY
DA FI ALB
INSPE 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 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
Final
Utility Notice (Perm)
COMMENTS:
^'p
1 1 11 1
T
T
tQ\ LJO
A RE-MSPEM014 fM OF $P_
.-
IMLLBECHARGEDSWEAPPROVED.
PLANS AND JOB CARE ARE NOT ON'
o THE 'SITS ,-f.OR IV- SCHEDULED.-,
mf=olt
MODMONS!
CITY OF LA QUINTA
BUILDING & SAFETY OEM
APPROVED
FOR CONWRUGTI J
sy
61
SII
Cq&,Tc
APPENDIX I
Appendix I . Container Spacing
7'Iris .9pprndix is not n part of the r•tquirrrntnts of this NF'PA docuinrnf het is inrinded for in%nrrnnlionnl purpose 0"I.
Oki Z old I ns s wctf4
men -
_
Intake to " -
f direct vent`s
appliance
nn 5 it '
Contra 'A/C u 'min. ~mfrs.~
compressor (Note 1b
(source of ignition) Not 3) `
DOT cylinders
not filled on site
Crawl space opening,
windows, or exhaust
fan
conditioner
(source of ignition)
/Min. loft- _
min.
(Note 3) DOT cylinder filled
on site from bulk truck
t .
Note 1: 5 -ft minimum from relief valve In any direction away Note 2: If the DOT cylinder Is filled on site from a
from any exterior source of Ignition, openings Into direct bulk truck, the filling connection and vent valve must be
vent appliances, or mechanical ventilation air Intakes, least 10 It from any exterior source of ignition, openings
Refer to Nola (b) (1) under Table 3-2.2.2. direct -vent appliances, or mechanical ventilation air ints
Refer to Note (b) (3) under Table 3.2.2.2.
(For SI units: 1 ft = 0.3048 m) Note 3: Reler to Note (b) (1) under Table 3.2:2.2.
Figure 1.1 DOT cylinders.
('Phis figure for illustrative purposes only; text shall govern.)
i •
Intake of direct
O\ van pPliance j-
` 1Nlndow air conditioner
11 in. 1 o ft M (source of Ignition)
Central A/C 0 (Note i) 5 ll Min. 10 ft (Nola 1)
compressor Min. 10 a ,~(Nota
(source of Ignition) (Note 1)12
Min. Voles
aiwc Min. oo• •0 Olt
loft (Note 2)
b tw Min Crawl space opening, Nearest line of adjoining /
25 h window, or exhaust fan property that may be /
t (Note 3) Min. 10 ft built upon
Min. 25 ft /
(For. SI Units: 1 ft = 0.3048 m) (Note 3)
Note 1: Regardless of its size, any ASME lank filled on Note 2: Refer to Note (b) (2) under Table 3-2.2.2.
site must be located ad that the filling connection and
fixed liquid level gauge are at least 10 h trorh any external Note 3: This distance may be reduced to no less than 10 f1(3 m)
source of ignition (i.e., open flame, window A/C, for a single container of 1,200 -gal (4.5-m3) water capacity or less
compressor, etc.). Intake to direct vented gas appliance or provided such container Is at least 25 ft (7.6 m) from any other
Intake to a mechanical ventilation system. LP -Gas container of more then 125 -gal (0.5-0) water capacity.
Refer. to Note (b) (3) under Table 3.2.2.2. Refer to Note (c) under Table 3.2.2.2.
Figure 1.2 Aboveground ASME conrafners,
(This figure for illustrative purposes only; text shall govern:)
G
T - d 6868 ZbE 09L O I aW I Sf:i9.I 83Wd
1995 Edition
dbS =Z0 .00 8T IAC
TABLE 8204-A
'TABLE
8212-A
TABLE 8204-A—LOCATION OF CONTAINERS
1997 UNIFORM FIRE CODE
'Minimum distance for underground containers shall be measured from the.pressure-relief device and the filling or liq-
uid -level gauge vent connection at the container, except that all parts of an underground container shall be 10 feet (3048
mm) or more from a building or line of adjoining property which can be built upon.
21n applying the distance between buildings and ASME containers of a 125 -gallon (473.2 L) or more water capacity,.a mini-
mum of 50 percent of this horizontal distance shall also apply to all portions of the building which project more than 5 feet
(1524 mm) from the building wall and which are higher than the relief valve discharge outlet. This horizontal distance shall
be measured from a point determined by projecting the outside edge of such overhanging structure vertically downward to
grade or other level upon which the container is installed. Distances to the building wall shall not be less than those pre-
scribed in Table 8204-A.
EXCEPTION: Installations in which the overhanging structure is 50 feet (15 240 mm) or more above the re-
lief -valve discharge outlet.
3When underground multicontainer installations are comprised of individual containers having a water capacity of 125 gal -
Ions (473.2 L) or more, such containers shall be installed so as to provide access at their ends or sides to facilitate working
with cranes or hoists.
4At a consumer site, if the aggregate water capacity of a multicontainer installation, comprised of individual containers
having a water capacity of less than 125 gallons (473.2 L), is 500 gallons (1892.7 L) or more, the minimum distance shall
comply with the appropriate portion of Table 8204-A, applying the aggregate capacity rather than the capacity per contain-
er. If more than one such installation is made, each installation shall be separated from other installations by at least 25 feet
(7620 mm). Minimum distances between containers need not be applied.
51he following shall apply to aboveground containers installed alongside buildings:
.Containers of less than a 125 -gallon (473.2 L) water capacity are allowed next to the building they serve when in com-
pliance with Items 2, 3 and 4.
2. Department of Transportation specification containers shall be located and installed so that t ch a from the
container t 3 f s b
ss for
discharge from container pressure -relief devices shall be located not less than
5 feet (1524 mm) from exterior sources of ignition, openings into direct -vent (sealed combustion system) appliances or
mechanical ventilation air intakes.
3. ASME containers of less than .a 125 -gallon (473.2 L) water capacity shall be located and installed such that the
discharge from pressure -relief devices shall not terminate in or beneath buildings and shall be located at least 5 feet
(1524 mm) the level of such discharge and not less than 5 feet (1524 mm)
from exterior urces o ignition, openings into direct -vent (sealed combustion system) appliances, or mechanical
ventilation air intakes.
4. The filling connection and the vent from liquid level gauges on either DOT or ASME containers filled at the point of
-' `- of ignition, openings into direct -vent (sealed
combustion system) appliances, or mechanical ventilation air intakes.
6This distance is allowed to be reduced to not less than 10 feet (3048 mm) for a single container of 1,200 -gallon (4542 L) water
capacity or less, provided such container is at least 25 feet (7620 mm) from other LP -gas containers of more than 125 -gal -
Ion (473.2 L) water capacity.
TABLE 8212-A—LOCATION OF CONTAINERS AWAITING USE
OR RESALE STORED OUTSIDE OF BUILDINGS
DISTANCES TO A BUILDING OR GROUP OF BUILDINGS, PUBLIC
QUANTITY OF LP -GAS STORED WAY, OR LINE OF PROPERTY THAT CAN BE BUILT UPON (feet)
x 0.4511 x 304.8 for mm
500 lb. or less 0
501 to 2,500 lb. 101
2,501 to 6,000 lb. 15
6,001 to 10,000 lb. 20
Over 10,000 lb. 25
'Containers may be located a lesser distance to buildings when approved.
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MINIMUM SEPARATION BETWEEN CONTAINERS AND
BUILDINGS, PUBLIC WAYS, OR LINES OF ADJOINING
PROPERTY THAT CAN BE BUILT UPON
CONTAINER CAPACITY
MINIMUM SEPARATION
BETWEEN CONTAINERS2.3
Mounded or Underground
Aboveground
(water gallons)
Contalnerst (feet)
Contalners2 (feet)
feet
x 3.785 for L
x 304.8 for mm
Less than 1253,4
10
55
None
125 to 250
10
10
None
251 to 500
10
10
3
501 to 2,000
10
255,6
3
2,001 to 30,000
50
50
5
30,001 to 70,000
50
75
(1/4 Of sum of
70,001 to 90,000
50
100
diameters of
90,001 to 120,000
50
125
adjacent containers)
'Minimum distance for underground containers shall be measured from the.pressure-relief device and the filling or liq-
uid -level gauge vent connection at the container, except that all parts of an underground container shall be 10 feet (3048
mm) or more from a building or line of adjoining property which can be built upon.
21n applying the distance between buildings and ASME containers of a 125 -gallon (473.2 L) or more water capacity,.a mini-
mum of 50 percent of this horizontal distance shall also apply to all portions of the building which project more than 5 feet
(1524 mm) from the building wall and which are higher than the relief valve discharge outlet. This horizontal distance shall
be measured from a point determined by projecting the outside edge of such overhanging structure vertically downward to
grade or other level upon which the container is installed. Distances to the building wall shall not be less than those pre-
scribed in Table 8204-A.
EXCEPTION: Installations in which the overhanging structure is 50 feet (15 240 mm) or more above the re-
lief -valve discharge outlet.
3When underground multicontainer installations are comprised of individual containers having a water capacity of 125 gal -
Ions (473.2 L) or more, such containers shall be installed so as to provide access at their ends or sides to facilitate working
with cranes or hoists.
4At a consumer site, if the aggregate water capacity of a multicontainer installation, comprised of individual containers
having a water capacity of less than 125 gallons (473.2 L), is 500 gallons (1892.7 L) or more, the minimum distance shall
comply with the appropriate portion of Table 8204-A, applying the aggregate capacity rather than the capacity per contain-
er. If more than one such installation is made, each installation shall be separated from other installations by at least 25 feet
(7620 mm). Minimum distances between containers need not be applied.
51he following shall apply to aboveground containers installed alongside buildings:
.Containers of less than a 125 -gallon (473.2 L) water capacity are allowed next to the building they serve when in com-
pliance with Items 2, 3 and 4.
2. Department of Transportation specification containers shall be located and installed so that t ch a from the
container t 3 f s b
ss for
discharge from container pressure -relief devices shall be located not less than
5 feet (1524 mm) from exterior sources of ignition, openings into direct -vent (sealed combustion system) appliances or
mechanical ventilation air intakes.
3. ASME containers of less than .a 125 -gallon (473.2 L) water capacity shall be located and installed such that the
discharge from pressure -relief devices shall not terminate in or beneath buildings and shall be located at least 5 feet
(1524 mm) the level of such discharge and not less than 5 feet (1524 mm)
from exterior urces o ignition, openings into direct -vent (sealed combustion system) appliances, or mechanical
ventilation air intakes.
4. The filling connection and the vent from liquid level gauges on either DOT or ASME containers filled at the point of
-' `- of ignition, openings into direct -vent (sealed
combustion system) appliances, or mechanical ventilation air intakes.
6This distance is allowed to be reduced to not less than 10 feet (3048 mm) for a single container of 1,200 -gallon (4542 L) water
capacity or less, provided such container is at least 25 feet (7620 mm) from other LP -gas containers of more than 125 -gal -
Ion (473.2 L) water capacity.
TABLE 8212-A—LOCATION OF CONTAINERS AWAITING USE
OR RESALE STORED OUTSIDE OF BUILDINGS
DISTANCES TO A BUILDING OR GROUP OF BUILDINGS, PUBLIC
QUANTITY OF LP -GAS STORED WAY, OR LINE OF PROPERTY THAT CAN BE BUILT UPON (feet)
x 0.4511 x 304.8 for mm
500 lb. or less 0
501 to 2,500 lb. 101
2,501 to 6,000 lb. 15
6,001 to 10,000 lb. 20
Over 10,000 lb. 25
'Containers may be located a lesser distance to buildings when approved.
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OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law' to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may. be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under Stave
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA92 3
(760) 777-70121
77-7012 /% /l
FAX: (760) it77- / 'J
OWNER'
D3 16 3M
PERMIT NUMBER(s)