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PLBG (0012-224)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's Exp,Date A. D ��,r fr� { �w i 2 / t �+f 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: ( ) . 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 0,erformance of the work for which this permit is issued. } Sec�) I have and will maintain workers' compensation insurance, as required by ion 3700 of the Labor Code, for the performance of,the work for which this permit is issued. My workers' compensation insurance ti arrier & policy no. -are: Carrier Policy No. STATE 01.1-ID"�, t�f-l�tt•1lC+14 2Q (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 Califo ia, and agree that if I should become subject to the workers' compens on prov;sions of Section 3700 the Labor Code, I-�ha9lforth,Gvith comply th �hose;�visions! � �� :ate: i-� � "".�' �"�'TAPplicant .er..rt°•rr` trJ� �� �_. �.t Warning: Failure to secure Workers' Com nsation coverage is unlawful and shall subject an employer to criminal pena ties 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 hereb luthorize representatives of this City to enter upon therabove-mentioned pfop rty forinspectionpurpos s'%�i J `Signature (Owner/AgnY)�*`%a�~Date r "'� V BUILDING PERMIT PERMIT# DATE VALUATION LOT E�CD.`�idi� TRACT JOB SITE APN ADDRESS 4-2255AVFJM')A:PJ 31.7t,'s.ZA. '174-4,22-021 1 OWNER CONTRACTOR / DESIGNER / ENGINEER MR. AND S, RICHM) la;..OX 1rNCd)3MNG Lit r,07 Ngr. 54-W AY17MDA ML114DOZA 68.175 LA�`�.�2C�� C,C7•MP LAQU 1+a'.E."A CA 92253 C`;A112A;31i.AL+;.:Cr`i' CA 92234 3577 USE OF PERMIT P1'..UMETWO SEPT3t; AR.A3JOOW.<'l:.t.'61i'g{.?. CC?mMerT. 14W-P()D P:iZ .11AC:T UW,21. 0 i VALUATION 13 F-917MAnD COST OF COMPRIMMOR PLUMMI-40 FEE 117KIWER 101 -000-439-000 L3 3 -TOTAL C OWSTR13MIOX A14D P1:.At3' fi'1'5rY. 530.00 . I S P!MPf'►%a RS RECEIPT DATE` r r / , BY DATE FINALED INSPECTOR 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 Hacks 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 OX for Finish -Plaster Sewer Lateral Pool Cover Sewer Connection — . ot e T Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final ` 6 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 Ter6p. Use of Power Final Utility Notice (Perm) HAMMER PUMPING INC. JOB INVOICE P.O. Box 2448 CATHEDRAL CITY, CALIFORNIA 92235-2448 Mani %an_7nn4 (760)321-7448 DESCRIPTION OF MATERIAL USED CUSTOMER'S ORDER NO. DTE RDERE �� ORDER TAKEN BY DATE PROMISED 0 A.M. ❑ P.M. BILL TO � PHONE ADDRESS MECHANIC..\, \ CITY G1 HELPER JOB NAME AND LOCATION //�1, liC J / 4 C.- L9 e / Q 0 DAY WORK DESCRIPTION OF WORK / 0 CONTRACT 0 EXTRA Out of Area Fee QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT Gallons Pumping Fee per 1000 gal. Q Dumping Fee per 1000 gal.' Out of Area Fee Locating / Opening Fee (per hour) Size System: A SERVICE CHARGE OF $20 WILL BE DUE ON ALL RETURNED CHECKS. 18% PER YEAR WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS. HOURS LABOR AMOUNT TOTAL MATERIALS MECHANICS @ HELPERS @ TOTAL LABOR I hereby acknowledge the satisfactory completion of the above described work: TOTAL LABOR TAX SIGNATURE DATE COMPLETED QTOTAL70��. Mar 02 01 07:26a Tri Star Cons. 7603217798 p.3 Construction & Excavation We dig the Coachella Valley Date. - Address: I, the undersigned, hereby accept the above listed lot, as is, following file septic to sewer Conversion. Ow"n". -s�igmmtur��— Umer Printed Name f Bus 760)321-08 0. Box 542, CW, e—dral —CjO,, C­4—fifOrjjia'--'- 1-11'4il.'TriSYara-cavate&of.c,ol,, 922-15 Fax (760) 321- 7798 63-02-01 07:17 RECEIVED FROM:7693217798 P.93 T 6 0 4hf 4 4 a" P.O. BOX 1504 Building 78-105 CALLE ESTADO Address 54-225 AVENIDA MENMIZA LA QUINTA, CALIFORNIA 92253 Owner Mailing Address p.p,B©g 1555 City Zip Tel. LA QUINTA 1 92253 1 564-1338 Contractor Address City Zip Tela LA QUINTA 92253 345-7659 State Lic. City & Classif. 5916$,4 Lic. # 1631 Arcn., tngr., Designer Address I Tel. CityI Zip I State Lic. # r/ LICENSED CONTRRACTOR'S DE LARATION I hereby affirm pat I am licelasd'adepprovisions�ohapter 9 (commencing with Section 7000) of Divi Ton�3�f thg Business d d rofessio��/ de, and my licen a is i full ( 2iand effectf�/�/iF}�yj�`tH� i�— i., c�j L/ OWNER -BUILDER DECLARATION 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, 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 civil penalty of not more than five hundred dollars ($500). ❑ 1,as owner of the properly, 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.) O 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 contractor(s) 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 Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) Policy No. .Company ropy is filed with the city. ❑ Certified copy is hereby furnished. e 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, 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, alter 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3 09 7, Civil Code.) Lender's Name Lender's Address 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. 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 BUILDING: TYPE CONST P. Number Legal Descript No. OCC: GRP. 13873 ject Description 4— 6 * 8" piers with 301f of 16" Wall. Sq. Ft. Size New ❑ No. No. Dw. Stories Units Add ❑ Alter ❑ Repair ❑ Demolition ❑ PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const. 15.00 Mech. Electrical Plumbing .S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by:_ Validated t Validation: N4.,/ CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SO. FT. ® $ UNITS SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) 2ND FL. SO. FT. FORMSSEWER YARD SPKLR SYSTEM POR. SO. FT. ® MOBILEHOME SVC. BAR SINK GAR. SO. FT. ® POWER OUTLET ROOF DRAINS CAR P. SO. FT. OTHER APP./EQUIP. DRAINAGE PIPING WALL SO. FT. TEMP. POLE DRINKING FOUNTAIN SO. 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.000L HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY 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 SPARK ARRESTOR SO. Fr. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 11/4 c SEWAGE DISPOSAL LATHING 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 FORMSSEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APP./EQUIP. 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 SIGNATURES/INITIALS GARDEN WALL FINAL 7d