BLDG (0307-043) + PLBG (10796)53200 Avenida Martinez
0307-043
10796
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
480121 B C20 C36 HI 09/30/2(
Date~ ~
X s 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:
Carrier STATE FUND Policy No. 1140909.03
(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 provisidns. rr/"
Date: Applicant—
Warning:
pplicant 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.
Signature (Owner/Agent) ! ' Date - , Z
_ -BUILDING PERMIT PERMIT#
DATE `• VALUATION LOT ' TRACT
q i 1021200 5.31300,00
JOB SITE
ADDRESS 53 2 )0 AVENWA J 17TIR"if APN
OWNER CONTRACTOR/DESIGNER/EN &NEER
DGH 1)EM,01y1+QF U CORP DOR DEiiM.0P1&QI M CORP
78-921 RUNAWAY BAY' 78-92) RUNAWAY BAY
BE+1WMAlll:iMS CA 92261 BERMUDi4'DUMS CA 92261
(760)360,f3706 C1:lh 1526
USE OF PERMIT
GEWR A.L I3t.i1T .L>IttiiC
144 LF. 6' BLOCK WALI, CITY STANDARD
6 FT. WALL
140,00 LF
ESMITATM COST OF CG►Y+TSI''Mi7C",C OR
FOO1K'X'I,' M hTMN ARY
CONSTRUCTION FFM 101.000-418.000 $63.00
.AND P'p. W MCS.
LEM PRE -PAID FEES
3.5(3( m
$63,00
$0.00
j
TTL MMMT YKEN DYE; NOW s ►.t a
t-.
RECEIPT DATEBY DATE F
NAL ID INSPECTOR
—Q
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 I
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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
P.O. BOX 1504 No. 1079-6,
Building 53a-200 Aire. Martinez 78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Owner ✓
Ms. Deltz M' Noble BUILDING: TYPE CONST. OCC: GRP.
Mailing
Address Same A.P. Number 774-962-027
CaZip Tel.
Qu .nta 92253 Legal Description
Contractor r . Project Description
L. L. Wilson Cons..ructiGn Sewer HookUp
P. a. Box 1687
CNdio ZIP42201 Tel342-2322
State Lic. City
& Classif. X2932,9 Lic. # Sq. Ft. No. No. Dw.
Arch., Engr., "
Size Stories- Units
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition,❑
Address Tel.
City Zip State
. .. Lic. #
LICENSED CONTRACTOR'S DECLARATION "
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) t. of Division 3 of the Business and Professions Code, and my license is in full force and
effec•;r '=v .,(,
SIGNATURE- J -; DATE
OWNER -BUILDER DECLARATION Estimated Valuation
^ y
I hereby affirm that I am exempt from the Contractor's License Law for the following 3 g 5ii V
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 rile a, signed statement that he is licensed pursuant *to PERMIT AMOUNT
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 703 1. 5 by 'any applicant for a permit Plan Chk..Dep.
subjects the applicant to a civil penalty of not more than rive hundred dollars ($500). -
O I, as owner of the property, or• my employees with wages as their sole compensation, will Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const.
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, Mech.
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 Electrical
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- Plumbing 30.00-,
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 S•M.I.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading
_ ❑ I am exempt under Sec. - B. 8 P.C. for•this reason
Driveway Enc.
Date Owner Infrastructure
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.
TOTAL 30.00
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS' COMPENSATION INSURANCE -
(This section need not be completed if the permit is for one hundred dollars (5100) valuation ?1pX i?1,Ga ft4ra.=- r_"S; p¢t,-
or less.)
I certify that in the performance of thg 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, ager making this Certificate of Exemption you should become ZONE:: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances:
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) Side Setback from Property Line
Lender's Name
Lender's Address FINAL DATE INSPECTOR
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. Issued by: Date Permit
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. Validated by:
Signature of applicant Date
Mailing Address Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
2ND FL. SQ. FT.
POR. SQ. FT. ®
GAR. SQ. FT. ®
CAR P. SQ. 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 APPJEOUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
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.
SO. FT. ® c
BATH TUB
FINAL INSP.
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1+/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
VENTILATION
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 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
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL