COMB (0101-220)53640 Avenida Martinez
0101-220
13829
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing Oith 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
r
peel ;%p- E Signatgre of Contractor
V r A
OWNER -BUILDER DECLARATIO.
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.
(,J) I have and will maintain workers' compensation insurance, as required by
Se,&on 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.
CLAP"0014 113% 0HKR0,022;180
(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 thpsepsiono r
(Date: f— tri 4Applicant
Warning: Failure to secure Workers' Com ensation 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 .fo'`inspectior J, purposes.
R —'-S Oent) gn
BUILDING PERMIT PERMITN
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS
APN _
Via --trS f Q AME -NIDA WHY.M. 7
OWNER
CONTRACTOR/DESIGNER/EN (NEER
1?pAizTi
; 4 , `. 11C.I)• -EOR : *PJ
Y3-64; iiaTi RE),4s'11/.Ml:l-rJ . {_."'D
3ISE
DR, 5;y P
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5N,T.t N .%(1LAf.•✓.R 4 'YS.LLA N.34.
LA QUIN TA. CA, 922
TP, Q1Wi'A CA 92233
(760)77 7. a'1180 CL
USE OF PERMIT
3Y.P,N)7ARD ONLY
'0''.A,LU.d4.'11ON ,OUq.UR L9
E119Y) MED C ORI OF CO14''b`Tal?1UC ?101K
k lwo.00
PERWITM SUMMARY
PLAN CHFOX.FIZE 101 000-439-318 9-605
Y..`JL4k8Ydl JH . AE', ii LO,i "l/0O"'b AG''"Vi.!L 1JY.' Lt
k i l,Ti f 313i;; `I;f:. 1t 1-00 . 3' •C bO X30: Uil
JAN 18 2001
t
"ITY
Qk1
$193.35
TOTKI, 3M MIT FEES ]DUE flow
RECEIPT
DATEBY
1118 161
DATE FINALED
INSPECTOR
V0
VI
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 % .=0Electric
Footings !
Bond Beam % .
Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
FinalZO/O
Underground Plbg. Test
Gas Piping
PLUMBINd 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 /. 4V
!
Encapsulation
Gas Piping 1;
Gas Test
Appliances
Final
Final
Utility Notice (Gas)•p ( %
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:
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From ' r .. it , (!r ( 5 _ !,
r
Address:
Account No.;s i // / ? / /r / l.). t Lot(s)
;=
Service Address o
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ Detector Check(s)
❑ MMeterSurcharge
-F' Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
082355/r
_ Date.' /„ 0
J -
Tract
G.A. Code
TOTAL
Remarks:
;t].Copy to:
Cash" Water Service
Check
s' - -- ----- _
'- — Cashier
Money '
Order CVWD-438.(11/89)
T a
4hf 4
P.O. BOX 1504 No, 13829
Building 78-105 CALLE ESTADO
Address 53-640 Ave. Martinez LA QUINTA, CALIFORNIA 92253
Owner Fairweather ; >r
Mailing BUILDING: TYPE CONST. OCC. GRP.
Address Sam
A.P. Number
CityZip Tel.
CZnintn, GA 92253 554=9232 Legal Description
Contractor Project Description
s$ ' £' A ; high block ' -
Uise Hanitenance a Construction patio flatwork and stucco
Addyjt85 Eisenhower Drive
Cita Qninta, CA Zip 92253 T1 .771-1180
State Lic. City.--
& Classif. 564238 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) of -Division 3 of the Business and Professions Code, and my license is in full force'
d
SIGNATURE DATE
OWNER -BUILDER DECLARATION Estimated Valuation ( ()p
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, after, improve, demolish, or repair any structure, prior to its issuance also AMOUNT
requires the applicant for such permit to file a signed statement that he is licensed pursuant to PERMIT
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 Plan Chk. Dep.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
❑ 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. 72. ciQ
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, 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.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing
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.1.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading
❑ I am exempt under Sec. B. & P.C. for this reason
Driveway Enc.
Date owner Infrastructure
WORKERS' COMPENSATIO DECLAt1ION
I hereby affirm that I have a certifica tte ofr e,
onsent b sel'-io or a certifi a of
Worker's Compensation Insurance, ora car led opy th o ec. f400, Labor Code.)
Policy No. Company
6o y is filed with the city. O at ie op i h y fur I e .
TOTAL 72.00
CERTIFICATE OF EXEMPTION FROM REMARKS
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, after 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 -j..,
work for which this permit is issued. (Sec. 3097, Civil Code.) Side Setback from Property Line -
Lender's Name // < 1
Lender's Address FINAL DATE INSPECTOR v
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 Fe
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives sof this city to enter the above-
mentioned property for inspection purposes. Validated by: ^ ( 4 t
Signature of applicant Date v
Mailing Address Validation:
City, State, Zip V _/
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
SLAB GRADE
^
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT. ®
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SQ. FT. @
FINAL INSP.
WALL SQ. FT.
WATER SYSTEM
DRINKING FOUNTAIN
GRADING
cu. yd.
$ plus x$
=$
URINAL
SQ FT ®
FINAL INSP.
FRAMING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FIRE ZONE ROOFING
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIREPLACE
LAUNDRY TRAY
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
FINAL INSPECTION
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 �— 3 -�L L�
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/ENITIALS
GARDEN WALL FINAL