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PLBG (0004-142)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division3 of the Business and Professionals Code, and my License is in full force and effect. License # Lic. Class Exp., Date 746159 C42 OV29/2f Date Signature of Contractor- OWNER-BUILDER ontractor 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 OOLDEN ZAOLE INS, Policy No. NWC543006-00 (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 riot 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:- 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 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) 7 �� /� Date/A r "Z . 11� Cj BUILDING PERMIT PERMI T# DATE VALUATION LOT"�4� TRACT $1,625.00 JOB SITE APN ADDRESS 536-920 AVExVWAItdWDO.ZA '774-173-00 OWNER CONTRACTOR / DESIGNER / ENGINEER MAYA JUUO\VF.WQUFZ, OFaJA ECONO MWER 9ER ViCE 53.920AVF.,41DM1yN'DO.?A 54035 CABAWNRD. TND.10, CA92201' LA Q7-WYA CA 92253 P1►i::M DEMT T C.A. 92261 �- (760)346-2793 CB.T.4- .342 1 , - USE OF PERMIT - PL-[1WWG t ' SEPTIC ABANDON • SENDER COUNECTION - LOW -MOD PROJECT INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE I 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 Q.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection — OXD Encapsulation Gas Piping Gas Test Appliances Final 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) COMMENTS: Building Address 53--920 Ave. Mendoza Owner Martin Rill e—m Mailing Address .Same City Zip 1 La. ¢ainta, CA 1 92253 P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 .564-2©06 Owner/Builder' - Address. - City State Lic. City & Classif. I Lic. # Arcn., tngr., 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 Law for the following reason:, (Sec. 7031.5,Suslness 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 file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) or Division 3 o/ the Business and Professions Code• or that. he is exempt therefrom, and the basis for the alleged exemption. Any violaWn of Section 7031.5 by 'any applicant for a permit subjects the applicant to a civil penalty of not more than rove hundred dollars ($500). [[]] I, as owner of the'property, or my employees with wages as their sole compensation, will dbithe work, and the structure is not Intended or offered for sale. (Sec. 7044, Suisness 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 bWrove for the purpose of.sale.) ❑ I, 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 contractors) #tensed pursuant to the Contractor's License Law.) ❑ 1 am exempt under Sec. r y B. && P.C. for this reason Ale % �) �J "' Owners ..w{�Ct�J�. �� 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: 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 (8100) valuation or less.) I certify that in the performance of tho 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,Callfornia, ,` 7 Date efl rrw Owner ?P + I is", ,�✓'A�s'lr / 1 : � , NOTICE TO' APPUCANT: d •, after making this Cdrrtl86ate`-of •Exeinption you should become subject to the Workers' Compensation provisions of the Labor Code, you- must forthwith comply with such provisions or this pemnit 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 properly filled out, signed and validated, and is subject to' expiration it 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-. mentloned property for inspection purposes. Signature of applicant Date Mailing Address City, State, Zip No. 14900 BUILDING: T.YPECONST.r OCC: GRP. A.P. Number Legal Description Project Description Install propane gas lame - Sq. Ft. No. No. Dw. Size Stories -Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ ZONE: BY: Minimum Setback Distances: Front Setback from'Cente Line Rear Setback from Rear p. ine Side Street Setback f enter ' e Side Setback from rty L' FINAL DATE PEC , Issued by: Date �y Prolt Validated by: `9195` Validation: Estimated Valuation $200.00 PERMIT AMOUNT Plan Chk.. Dep. Plan Chk. Bal. Const. Mech. ' Electrical Plumbing 30.00 S.M.I. Grading Driveway Enc. Infrastructure TOTAL 34'?'j . 0Q REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from'Cente Line Rear Setback from Rear p. ine Side Street Setback f enter ' e Side Setback from rty L' FINAL DATE PEC , Issued by: Date �y Prolt Validated by: `9195` Validation: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBINU FEES 1ST FL. SO. FT. @ $ 2ND FL. SO. FT. POR. SO. FT. @ GAR. SO. FT. @ CAR P. SO. FT. WALL SO. FT. SO. 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 SO. FT. @ c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID @ 11/4 c SEWAGE DISPOSAL 90 S �oznJaa RiQ� �ONSiTLY' .L��"l 04 77 N/- �f� SO.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. STEELGAS (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. 3 �� ,�S ROOFING 90 S �oznJaa RiQ� �ONSiTLY' .L��"l 04 77 N/- �f� 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/INITIALS GARDEN WALL FINAL