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COMB (0211-191)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 622969 C36 C20 S 7/31/03 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: ( ) 1, 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 1 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. 163awo-02 (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:i, 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) 4,-� Date XN BUILDING PERMIT PERMIT#0211-191 121•S-x9x VALUATION Z 3 1 LOT TRACT DATE 1112"2 JOB SITE ADDRESS 52-1f;fSU'' AYKMAAMMOM APN - - OWNER CONTRACTOR/DESIGNER/EN (NEER FRANCISCO MU)IOZ MhRAVILLA FO•C1I~IDAr6 J14 32-680AVEMAWAMLA 5729 UNION'PA•CJT"1C'AVI� to QUYNTA. CA 92M ClTY Of COMMIMCM C.F . ` 3022 (323}a21-8883 03114 USE OF PERMIT CO~>�It7.ATIC: �t RKPLAZZ WATLIZ HI .AT_Y1R. AND PUT,.N.ACE (UNDER 100,M BTU) "LU.A.TION 1,800.00 1.S ES'1."IMA.'1'M COST OF COPSYRUC170N 1,000mo FERMC. 4WE i9rUi MARY PJ, YM0111C1 FEE 101.000419.000 $22.50 M C3iANii'.1hL ISE 10t-000.421-000 314.w s ,f„ i ?1I1I-'IMAL C4A0''MUC'3101: AND PLANT r1F�.:`1i 'x;46.130 I 1=3 PRF,-.1A1D x�S $000 i RECEIPT DATE * ;BY DAT INSPE `INAIED O C!!�� 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 Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances W"A j 2 2 H eA, a /L� _ Final COMMENTS: 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 Final Utility Notice(Perm) 4 � _ 1 P.O. BOX 1504 Buildiimj 52-680 Avenida Mendoza 78-495 CALLE TAMPICO Address LA QUINTA, CALIFORNIA 92253 La Quinta Palms Realty Mailing Address 8.0. Box 346 CityLA Quinta Zip 92253 Tel. 5644144 Contractor NuI bib Inc Address P.O. Bax 1555 City Zip Tel.: L Quinta 97253 554-4104 State Lic. & Classif.. 537333 City Lic. # 2526 Arch., Engr., Designer Address Tel: City Zip State Lic. # LICENSED CONTRACTOR'S DECLARATION, J hereby , 1rm that) am line" under provisions of Chapter 9 (commencing with Section ^ 000) of Divi I 'R 3 ',f tthe Business and Professions Code, and my license istinfull force and effect. f WV 4 ?. 1�. t ..Lbzi-II 31GNATURE t t DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason: (Sec. 7031.5,Susiness, 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 requires the applicant for such permit to rile 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 o/ 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 penafty of not more than five hundred dollars ($500). ❑ 1, 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.) ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to com. 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 con(ractors) 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 Workers q9iApensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) Policy No Company i,¢�Copy is filed with the city, O 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, 1 shall not employ any Ufrs ppeon in any manner so as to become subject to the Workers' Compensation Laws of Ca ornia. _ Date Owner NOTICE -TO APPLICANT. N, 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 ($100,000), 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 property 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 statelaws 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. 15838 BUILDING: TYPE CONST.' OCC: GRP. A.P. Number Legal Description Project Description Sewer Caanect/Si6ri iC Abond n Sq. Ft. No. No. Dw. , Size Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation $1,000.00 PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const. , $30.00 Mech. Electrical ' Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL $30.00 REMARKS' 'ZONE: BY: Minimum Setback Distances: Front Setback from Center! Rear Setback from Rear. Line Side Street Setback m Cente Side Setback from Proper�i Ine 0 FINAL DATE 1N§FiFrTnR Issued by: Date �� Pe * r 7 y �, Validated by: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBINU FEES 1ST FL. SO. FT. ® $ 2ND FL. S0. FT. POR. SO. FT. ® GAR. SO. FT. ® CAR P. SO. FT. WALL SD. FT. SO. FT. ® ESTIMATED CONSTRUCTION VALUATION $ UNITS MOBILEHOME SVC. POWER OUTLET YARD SPKLR SYSTEM BAR SINK g ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING NOTE: Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES HEATING (ROUGH) WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER DUCT WORK GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM HEATING (FINAL) 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 BOND BEAM SO. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 11/4 c SEWAGE DISPOSAL LUMBER GR. SO.FT.GAR ® 3/<c HOUSE SEWER FINAL INSP. ROOFING 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 S�E1/�ER R Sf+PT 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. f/l TWA 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 ::d COACHELLA VALLEY WATER DISTRICT ,i CASH RECEIPT DETAIL U �uavvp—, ❑ Other Remarks: ❑Copy to: Cash j Check �% �� �•• �� Money I Order 2. TOTAL I Water Service Cashier / /. CVWD-438(11189) Received From: / - <, ~ �_ n �i.1 v' .i 1 1 •I Address: Account No. �� �' l r �� i"C %7.1 P 1/ 4 7 ��• Service Address n ❑ Meter(s) ❑ Service(s) ❑ Backflow(s) ❑ House Lateral(s) ❑ DetectorCheck(s) ❑ Meter Surcharge AJ Sanitation Capacity Charge J ❑ W.S.B.F.C. ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee - Tract - Fee - ❑ Plan Check Fees Water / Sewer - Tract - C3 Bond Payment - A.D. - Bond Assmt. U �uavvp—, ❑ Other Remarks: ❑Copy to: Cash j Check �% �� �•• �� Money I Order 2. TOTAL I Water Service Cashier / /. CVWD-438(11189) 2502 Morongo Trail Palm Springs, CA 92264 (619)327-8859 - N2 9630 -SOLO TO MS r72o F.O.B. U" I I-Fluo W%A 24f,'-Xiol STRZKT . NO. STREET NO. SZ -K. C I STATE ZIP CITY STATE ZIP Ov A, 1 4 1 C TOM-F--rER ISR ORDER SALESMAN MS r72o F.O.B. DATE 7- PAYMENT DUE UPON RECEIPT