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PLBG (112-096)51371 Avenida Martinez 0112-096 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: ( ) 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 6oAtractors to construct the project (Sec. 7044, Business & Professionals Code). ( ) I am exempt under Section , B&P.C•: for this reason Date %i . NP rt Signature of Owner r;V-71,- Wt F✓. t' 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 -ATS FUND Policy No. 1424286-IJI . (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 It ose provisions. . bate: /V, // of / 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 tos: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 forinspection purposes. Signature (Owner/Agent..cf ✓ f r,/!lTl Date= ' 'BUILDING PERMIT PERMIT #M1210 DATE Ii2t , VALUATION {N E LOT= : ; TRACT JOB SITE ADDRESS M-171 . AIMM4 Nid+lRrINt .,i . APN OWNER CONTRACTOR / DESIGNER / EN (NEER 784380viAvEly COPIA C160)$64-62'16 CELO' 3147 USE OF PERMIT PLONMOG t a t ; . ,t r, r. ,wr u z: • Tz s sz , r:u .a a VALUATIO)i L.1% b"`. . }'I. u11flBiNo .mr... mmin 101-000-4)9-000 SX in DFC 11 zoos W'OFLA ire l • -a.'C►`faAL O t :t1°C;'x` f 'k '.t' Fi ;,A F:: ' rg I'm lyn P,10 ism $0,00 'MAI, PERM 44 S ]XV. NOW 00.00 RECEIPT DATE IDATE'FINALED INSPECTOR /2 /4 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 POOLS - SPAS BLOCKWALL APPROVALS 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 Sewer Connection Pool Cover Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: j 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) COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL Remarks: - ®Copy to: Cash Check. J Money Order . J Z ; /r,,.J G.A. Code TOTAL $ 1 ^ ? CJcl Water ServIc Cashier CVWD-438 (11/89) Received From: C Address: alC L Account No. - ✓ `r L:Q (J Lot(s) ." Service Address -.j -7.1 117 ❑ Meter(s) ❑ Service(s) r ❑ Backflow(s) ❑ House Lateral(s) ❑ Detector Check(s) ❑ Meter Surcharge P"'Sanitatlon Capacity Charge ❑ W.S.B.F.C. ❑ Temporary Construction Meter P 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: - ®Copy to: Cash Check. J Money Order . J Z ; /r,,.J G.A. Code TOTAL $ 1 ^ ? CJcl Water ServIc Cashier CVWD-438 (11/89) Building Address 51-371 Martinez OwMichaelMulvaney Address P.O. Box 4¢$ P.O. BOX 1504 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 — City Zip Tel. La Quintas C3 32253 1 564-0866 Contractor O=er/Builder - Address City lZip State Lic. I City & Classif. Lic. # Arch., Engr., Designer Address Tel. CityI Zip I State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am 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 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 thathe 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). GAT,a`s 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.) ❑ 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 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 net 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 i1 the permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance of lhg 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 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 BUILDING: TYPE CONST P. Number al Description Project Description Gas Test No. 13233 _OCC. GRP. Sq. Ft. No. No. Dw. Size Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation $50.00 PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing 30.00 S.M.I. Grading Driveway Enc. Infrastructure TOTAL t U _ REMARKS I 1 J Y ZONE: BY: Minimum Setback Distances: ALine Front Setba k from Center Rear Setba rnC R CeCCa r PrSide Street t a& frttmgSide Setbac r m Property FINAL DATE Issued by: Date Permit Validated by: Validation: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES IST FL. SQ. FT. @ $ UNITS SLAB GRADE a BONDING YARD SPKLR SYSTEM 2ND FL. SQ. FT. @ FORMS SEWER OR SEPTIC TANK POR. SQ. FT. ® MOBILEHOME SVC. BAR SINK GAR. SQ. FT. @ POWER OUTLET ROOF DRAINS CAR P. I SQ. FT. OTHER APPJEQUIP. DRAINAGE PIPING WALL SQ. FT. TEMP. POLE DRINKING FOUNTAIN SQ. FT. @ GROUT URINAL ESTIMATED CONSTRUCTION VALUATION $ FINAL INSP. WATER PIPING NOTE: Not to be used as property tax valuation WATER SYSTEM FLOOR DRAIN MECHANICAL FEES _$ WATER SOFTENER VENT SYSTEM FAN EVAP.000L HOOD SIGN WASH ER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY AIR HANDLING UNIT CFM 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. SQ. FT. @ c BATH TUB SPARK ARRESTOR SQ. FT. @ c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID @ 11/a c SEWAGE DISPOSAL LATHING SQ.FT.GAR @ 3/ac HOUSE SEWER 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) ?-Io—cI3404 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 INSULATIONISOUND FINISH GRADING FINAL INSPECTION,? -10 _ CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES/INITIALS GARDEN WALL FINAL 71