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BLDG (0302-051)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 'If 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 Policy No. (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 4that if I should become subject to the workers' compensationprovisions of Section 3700 of the Labor Code, I shall forthwith comply with those�Rrovisions..0' 'Date: Applicant Warning: Failure to secure Workers' Compensationco erage 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 t BUILDING PERMIT", -, PERMIT# l S DATE VALUATION] LOTTRACT "°r t JOB SITE w Z': ADDRESS ,iy2^.�1 A P7H)i� AN.I}Ah APN OWNER CONTRACTOR / DESIGNER / EN INEER MA�i.'�( RE 32«319 AVEV O)A N'lx NDO .A L& QU N't A CA .92253 CBI*. USE OF PERMIT c:°if, ,f11RA .1'3LT.LLP,1NG 230 'LF 6' WRr?*1 WALT. (9' it WOWT P1tOP1' R7Y JiNK),C1T•Y' STANDARD FOOTIl I 6 F'r. WALL 200.00 LF Ri�'f"�'iaV1*HM COST 'OF C0093ItUCTIon �a(11it31�i Ph i f►`'16~ subm AR.w>r CONSTRUCTION FEE 101-000-418-000 MAD n T N7tf�E.~F'dt7N A PLAN c:.c�'Y32.4t) M :Ems PRE -PAID FEE3 $0,00 ju cr Ma 1 z o al'AL }: KRMU TFT S XWE NOW "7100 D w RECEIPT DATE i ` BY DATE FINALED INSPEC 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 'i BLOCKWALL APPROVALS Steel Set Backs — Electric Bond Footings Main Drain Bond Beam _ _x7ZEl d 3 _ a Approval to Cover Equipment Location Underground Electric _ Fink Fine �7/ 02 Underground Plbg. Test 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 COMMENTS: Final 100lity 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 Final Utility Notice (Perm) OWNER/BUILDER INFORMATION Dear Property Owner: An application for a building permit his been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners. unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors,.then you may be an employer. If you are an employer, you must register with the State and Federal Government as an employer and you are subject to several obligations including State and Federal income tax withholding, federal social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There may. be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to worker's compensation insurance. For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under Stare Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N. Street, Sacramento, California 95814. - Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico La Quinta, CA 92253 (760) 777-7012 FAX: (760) 777-7011 .y OWNER'S SIGNATURE/DATE s Z Ste/ f ~nDa? A 44 PROPERTY ADDRESS o3o�i PERMIT NUMBER(s) 4 P.O. BOX 1504 Building 78-495 CALLE TAMPICO Address 52-519 Avenida Mendoza LA QUINTA, CALIFORNIA 92253 Lew Newman Mailing Address sane as above City Zip Iia Qui.nta 93253 Contractor Roar Tile Suecialt LDING: TYPE CONST P. Number 6:16-795-4755 1 Legal Description_ Project Description Palm Desert 92260 341--6073 State Lic. City & Classif. 636394 Lic. # 1420 Arch., Engr., Designer 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 and effect. SIGNATURE DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Lawfor 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 chit) 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 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 knprove for the purpose of sale.) O 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) (kensed 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, ora 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 ($100) valuation 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: 1f, 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. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,00(3), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. 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 car lfy 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 P Ne -roof No. 1.575, OCC. GRP.- 616-795-4755 RP. Sq. Ft. Size No. Stories No. Dw. Units New ❑ Add ❑ Alter ❑ RepairXX Demolition ❑ Estimated Valuation $C500.00 PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const. 30..00 Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL 3f) _ 00 REMARKS -ZONE: BY: Minimum Setback Distances: Front Setback frot Line Rear Setback firar Pro ine Side Street S fro ine Side Setba om erty L \ e p FINAL DATE eL INSPECT6 Issued by: Date 1l �jj 3i Validated by: /� Validation: 1 CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBIW FEES IST FL. SQ. FT. ® $ UNITS SLAB GRADE 2ND FL. SQ. FT. BONDING YARD SPKLR SYSTEM POR. SQ. FT. p MOBILEHOME SVC. BAR SINK GAR. SO. FT. ® POWER OUTLET ROOF DRAINS CAR P. SQ. FT. GAS (ROUGH) DRAINAGE PIPING WALL SQ. FT. OTHER APPJEQUIP. DRINKING FOUNTAIN SQ. FT. ® - TEMP. POLE URINAL ESTIMATED CONSTRUCTION VALUATION $ GROUT WATER PIPING NOTE: Not to be used as property tax valuation FINAL INSP. FLOOR DRAIN MECHANICAL FEES WATER SYSTEM WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER FINAL INSP. GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED 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. SO. FT. ® c BATH TUB SQ. FT. ®c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID ® 11/4 c SEWAGE DISPOSAL SO.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) 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 /A/ REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION �� 9 CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL 4 P.O. BOX 1504 No. 13101 Building 78-105 CALLE ESTADO Address 52-519 Mendoza LA QUINTA, CALIFORNIA 92253 Owner Mailing los • Kim Newmann BUILDING: TYPE CONST. OCC. GRP. Address Same A.P. Number City Zip Tel. La Quinta, ,CA 92253 Legal Description Contractor Project Description Sewer Hook-up Hendrickson Construction Address 68-315 kieley Road Cathedral C3.t3►ripCA 92234 T328-1747 State Lic. 25�1i34"A City & Classif. Lic. # 194 Sq. Ft. No. No. DIN. 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 Divisiion 3 of t�hG_,e�gusiness and Professions Code, and my licePse is in full force and 1 effect. J�� �1��_ if {r ..? t.Lf SIGNATURE'- DATE OWNER -BUILDER R DECLARATION Estimated Valuation $2r850.00 I herebyaffirm that I am exempt t fromfrom 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. 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 JU (110 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. Dale 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.) Polico y�Company E Copy is filed with the city. ❑ Certified copy is hereby furnished. TOTAL r30.00 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 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, 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 work for which this permit is issued. (Sec. 3097, Civil Code.) Side Setback from Property Line Lender's Name Lender's Address This is a building permit when properly filled out, signed and validated, and is subject to FINAL DATE INSPECTOR expiration if work thereunder is suspended for 180 days. I certify that I have read this application and stale 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 IST FL. SO. FT. ® $ UNITS SLAB GRADE ROUGH PLUMB. BONDING YARD SPKLR SYSTEM 2ND FL. SQ. FT. FORMS SEWER Q POR. SO. FT. ® MOBILEHOME SVC. BAR SINK GAR. SO. FT. ® POWER OUTLET ROOF DRAINS CAR P. SQ. FT. OTHER APPJEOUIP. DRAINAGE PIPING WALL SQ. Ff. Q 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.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED 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 SPARK ARRESTOR SQ. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID ® 11/4 c SEWAGE DISPOSAL LATHING SQ.FT.GAR ® 3/ac HOUSE SEWER MESH GAS PIPING PERMIT FEE INSULATIONISOUND 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 Q UGH WIRING DUCT WORK ROCKSTORAGE 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 INSPECTIOtg23,93 CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES/INITIALS GARDEN WALL FINAL