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BLDG (0207-096) + PLBG (12624)53930 Avenida Madero 0207-096 12624 _ 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 B C27 Dated " 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: ( ) 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: CarrierWD-CENTURY Policy No. AD14849-,y (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 provisio s ,of Section 3700 ,ofthe Labor Code, I shalllforthwith comply with those provisions. Date: ;'` `ti Applicant_ ••" 1 L Warning Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for.inspection purposes Y 7 /Signature (Owner/Ageni) BUILDING PERMIT PERMIT# DATE VALUATION _, LOT TRACT I JOB SITE ADDRESS?. 7 A v cv i inn 1iiS _ OWNER CONTRACTOR/ DESIGNER /ENGINEER pL L y,e JTO:L haM4 CxC11110:V 53-930 AVIDOMAMAIXAMID 4`l555 YILTCCAt LAAM, LA, Q•L9'LNTA C.A.. 59222 RF t9R$ C'A vY• 9`` 2201rr // rr ippYX3r'(( f pp p! yy CJ li,3150-' 400 4. hA 7W USE OF PERMIT Cs l?T AIL B''UFIl DDZG :50 JLP 6' CDl3.RMN' WALUM LP Cat9M;alNATIOV 198RETAiNINtt $i'IT14 MAPMEN iVAL. L -AU, PER Cr'iMSTAHDAISM 6 i, WALL 80,00 LF ITWM- A `.Ib'1D Cd3VU OF CC,>dd5' .'tii:'FION CONIS7'RUOTION FEE 101-000,418.000 '%4SM x, - pp r pp tt A S 2' - /11,0 L CITYof LAQUINTA FINANCE DEPT. N. SUB TC3fAL CCJI F . 12b 'Ca°iON AM PW14 NICD:: ` 't..f',C2 LEM FRE-PAU M-3 $0.00 rP"1 RECEIPT DATE 6 BY DAT FINALED INSP TOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVAL'S 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 p. Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Final / a7yl / PLUMBING APPROVALS Underground Plbg. Test Gas Piping Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sevier 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: Building 53-330 A HIDA iMERO Owner JOHN & DORIS SPOLARICH P.O. BOX 1504 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 Mailing Address SANK City Zip Tel. LA QUINTA 1 92253 564-2150 Contracitori SHSPOOL Address Zip I Tel. State Lic. City & Classif. Lic. # Arch., Engr., Designer Address Tel. CityI Zip I State I Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70 130) 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 Contractor's License Law for the following 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 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 ($500). O 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.) O I, as owner of the property, am exclusively contracting with licensed contractors to con- struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) ❑ 1 am exempt under Sec. B. & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) Policy No. .Company ❑ Copy is filed with the city. ❑ Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($ t 00) valuation or less.) I certify that in the performance of thip 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 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, State, Zip No. 12624 BUILDING: TYPE CONST. OCC: GRP. A.P. Number 774--143-010 Legal Description Project Description SBWR CONNRCTION 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 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 PropelLine + FINAL DATE Issued by: Date_ Validated by: Validation: t._ CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SQ. FT. ® $ UNITS COLL. AREA r ROUGH PLUMB. 2ND FL. SQ. FT. HEATING (ROUGH) YARD SPKLR SYSTEM POR. SQ. FT. ® MOBILEHOME SVC. BAR SINK GAR. SO. FT. ® POWER OUTLET ROOF DRAINS CAR P. I SQ. FT. DRAINAGE PIPING WALL SQ. FT. @ HEATING (FINAL) DRINKING FOUNTAIN, SQ. FT. ® URINAL ESTIMATED CONSTRUCTION VALUATION $ WATER PIPING NOTE: Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES FINAL INSP. WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GRADING cu. yd. $ plus x$ GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY AIR HANDLING UNIT CFM FINAL INSP. 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. SQ. FT. ® c BATH TUB FIRE ZONE ROOFING SO. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 11/4 c SEWAGE DISPOSAL SO.FT.GAR ® 3/ec HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FE7 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 SEWER ROUGH WIRING DUCTWORK ROCK STORAGE 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 � O REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION/? —30-,7 3 CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES/INITIALS GARDEN WALL FINAL 13 COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL Received From: Address: '—� Account No. Lot(s) r Service Address ❑ Meter(s) ❑ Service(s) ❑ Backflow(s) ❑ House Lateral(s) ❑ DetectorCheck(s) ❑ Meter Surcharge Manitation Capacity Charge ❑ W.S.B.F.C. ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee - Tract - Fee - ❑ Plan Check Fees Water / Sewer - Tract - ❑ Bond Payment - A.D. - Bond Assmt. ❑ Customer Deposit ❑ Other Remarks: N° 46406 TOTAL ❑Copy to: Cash y Water Service Check Cashier Money OrderQ_ CVWD-438 (11 /89)