SATT (9808-011)51030 Mango
9808-011
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.
Licensed#10745 Igfp. Class Exp. Date t}
Date L Signature of Contractor t= A g
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 i'M USTIZIAL IND041 Policy No. CN90,18=4
(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 shall forthwith comply with those provisions.
Date:? vApplicant Q 4
Warning: Failure 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.
Si nature (Owner/A ent) I 1,A ► Date
ERMITJ{jj},( ; CONTROLl
yWtt9g{BUILDINCLPaERMIT p 24890-2
DATE VALUATION LOT TRACT
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JOB SITE "} ' '+ a
APN J " -
ADDRESS
OWNER
INC
CONTRACTOR / DESIGNER / ENGINEER
CAPUALPACIFI.CVIOMB. MIC:
4100 lNiACAR'3"iriM BLVD #200
4100 A -GIC AR'T'HUR BLVD 0200
NEWPORT BEAC14 CA §2660
Ni:ViAL1.RT BEAC. It (.!A 92660
USE OF PERMIT
PAMILY ATFAf HED
f•z" X Al It Off `h CT+ T'n."`.. `+1i t..tf fp
•a,fYT '.I V. YYX
w r>. a.vra>. .ot + +.art .a ♦ 4 as V.t-ra+.aa x
W.11LLS OR Y001.. PLAN Ch3FG'K..F. itE9)i3CED BY ",P/cc,' 011 lL1tJi.:t"IPUB
:SSY.r4Idi?"5OF 1.AMS.PLAN WP1
CUST01 i CONSTRUCTION Z012,00 3F
PORCRPAI°i!O 2100.00 .V
GA.i2ACF VCA:2PORT £ 17.Ot3 Sl
STA IA'. L, D CUSS 0AN C ONSI'P MMON
215,816.00
CON SYRUCT10NFEE 1.01-0%L41MOO ii3OS6.00
PLAN CHECK Fes' 0 -000-439-318,
SvcX3IANICA1, fes; 101-()CO-d2.'a-(1QQ $y2.
2,FC t12SCAL r'L:1, 101-000-420-000 V61.86
1 u tt t 10.1-0c)(J-419-000 S167.r)
SITOYNO MOTION FE - RFSID' ICIA -000-241-00`? 521,83
CRADING MS 101-000-423-000 $510.00
INFRASTRUCTC7RE M 225-000-443-342 $-1.86151
PRF+CISE• PLKN 101.V)0-441-345 $125:00
ASST IN P(MLIC PLACE..14 - atF3J] e01 -OW -255-000 5207.04
SUB -TOTAL C•ONS'TRUarION AND PLAN? CIHF.0 X
$6,919.62
LESS; Pfl]- -PAID FEES
$0.00
TEYItAL 6''ERY4`[:IT'FUN DUE NOW
S6,9,19.oz
RECEIPT
fir ±
DATE
BY
DATE FINALED
9'
INSPECT
t'7'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION '
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
���j-Cf
��
Underground Ducts
Forms 8 Footings
p
Ducts
Slab Grade
i
�"
Return Air
Steel
Combustion Air
Roof Deck
_1�, q�
��
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Insulation
— j K
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Eli-2:75EE�GL(
Drywall - Int. Lath
Final
Final �/CS - ��J 2Gr
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
Water Piping
p�
/-2.
io
Heater Final
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
I
Rte• -
Final
Utility Notice (Perm) .•��- �' �/
COMMENTS:
-
.
Building 5I -M
Address ai#QQ
Owner
Mailing
Address
City Zip Tel.
Contractor
Tela
State Lic.I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
Lic. #
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
LICENSED CONTRACTOR'S DECLARATION
I hereby fj' mAthat ('.am li11 ce fsed under provisions of Chapter 9 (commencing with Section
7000) of D1Yls o y3bf Tt:!ft3Iress and Professions Code, and my license is in full force and
effect. i ) tf li 11 ti P,+ ..•
OWNER -BUILDER DECLARATION
I hereb affix tha I am exempt from the Contractor's License Law for the following
L ason: (Se 70 1.5, siness and Professions Code: Any city or county which requires a
permit to cor%truct, 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) or
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 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, 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.)
❑ 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
opy 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.
Date Owner
NOTICE TO APPLICANT: If, alter 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
Ihereby 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 if 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. 07796
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number CitmS Own
Legal Description Tract 24NO-2 Plan 2A
Project Description L40t 4?_
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
18794M
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
r
Mech.
Electrical
125.69
Plumbing
156.50
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
6.304.W! n , 't 41
S7rfi€..,47-13-911,, .,,,
IQ
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 5/4/90 Permit
Validated by:
Validation:
CCNSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
2ND FL. SO. FT.
POR. SO. FT. ®
GAR. SO, FT. ®
CAR P. SO. FT.
WALL SQ. FT. ®
SQ FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEMIPERM
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.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
HOUSE SEWER
REMARKS:
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
SEWER OR SEPTIC TANK
ROUGH WIRING.
DUCT WORK
ROCK STORAGE
FOUND. 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
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
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL ::d