9805-112 (PLBG)LICENSED CONTRACTOR DECLARATION
�;I;hereb; 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
70 14 14 A � �1l3II3•�
Date —94Signature of Contractor _IZ or, I
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's y,
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 that if I should become
subjectit'o the workers' compensation provisions of Section/3700 of the Labor
CAe 4shall forthwith comply with those provisions
yD`ate:
—1/—ix�Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. `
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall,,, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
1. /_`", %
,rZnature (Owner/Agent) /—/, �/ �', /L_ Date <_ 7 -
•BUILDING PERMIT
PERMIT# .• CONTROL#
DATE �>!_Z+<1a� VALUATION LOT , y TRACT7790
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JOB SITE
ADDRESS=",-irY4l� AV91'41 ��4 dile$ 0
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OWNER".'
CONTRACTOR / DESIGNER / ENGINEER
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34-693 A'oFENIDA.1btAiik;M
-LA. QCJi'tV'4: A CA 4275:4
L.A QL11?�'A C -A 92253
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M.Y.,# 114
USE OF PERMIT
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RECEIPT DATE BY 1 DATE FINALED INSPECTOR
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INSPECTION RECORD
OPERATION
PATE
INSPECTOR
OPERATION
DATE
INSPECTOR
'J BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0.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
Neater 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
nces
Final
COMMENTS:
Final ,
Utility Notice (Gas) -yY
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
Wilily Notice (Perm)
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL es . •:?3 G i
Received From: ��� !� / Date:
Address: �j �' '/ (' <: ? J ' -i r N P✓ i� L G9� (/ iS�? ��
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`i Account No. E % Ir ^ 3 -� ('- % fJ. [? Lot(s) q Tract
Service Address zi� ��a� � ` , G.A. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s) t
❑ Meter Surcharge
]sanitation Capacity Charge C 1
❑ 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
TOTAL $
Remarks:
dopy to:
Cash Water Service
Check
Money Cashier
Order ;4
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APPLICATION FOR TREE PLANTING Job 92.5-32
I (we), the undersigned,.hereby certify and acknowledge that I (we) have read the application and agree that if trees are required under River-
side County Ordinance No. 457, the applicant agrees to install said trees prior to final inspection. It is understood that no final inspection
will be given until said requirements hove been met or exception has been granted by the County. Now, therefore, it is agreed that the prop-
erty owner shall cause the property lines to be surveyed in the event no survey stakes can be found. Further, it is agreed that the County of
Riverside shall assume no responsibility should trees have to be removed due to lot line errors. c�
Owner's Name W & H BUILDERS Building Permit No. L "c7 - d 6
Mailing Address 12540 Palm Dr. P 0 Box 818 DesertcliQt Springs state C zip 92240
Job Address 53640 Avenida Rubio Community La Quinta
Legal Description Lot 19. Blk 190 Unit 19 Santa Carmelita at Vale
Assessor's Map, Book & Page Type Structure Dwelling
Type of Soil sand Is water available yes Road DeR Plot Plan No.
Type of existing trees in road right—of—way
Trees preferred by applicant (1) Olive (2) Palo Verde �— (3)Brazilian Pepper
W & hV BU ILDER i
Date 9 Petr 1979Owner's Signature
Planning Commission Case No. PERRY C
ROAD DEPARTMENT APPROVAL
Approved species Washingtonia robusta (Mexican fan palm) Number of trees 1
Spacing of trees Distance from lot lines: Front 2' in R/W Side
Additional requirements Per plot plan on reverse.
Date Building and Safety notified 5/79 Signature
REQUEST FOR EXCEPTION
Reason
Request for hearing:
Owner's Signature
Planning Dept.
Concur ❑
Dais
YES ❑
(attach additional page if necessary)
i
(Forward application to Planning Dept. if exception requested)
NO REQUEST FOR HEARING
Non -concur ❑ Explanation
Signature
Road Dept.
Concur ❑ Non -Concur ❑
Date Signature
REQUEST FOR HEARING AND COMMITTEE'DECISION
Date hearing established Date hearing notice mailed to owner
Approved ❑ Disapproved ❑ Date Owner notified of decision
Date Building & Safety notified Signature
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NOTICES, NTHISIS NOT A BUILDING PERMIT
t APPLICATION TO CONSTRUCT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF RIVERSIDE
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DISTRICT
Permit No
40 'x'2 .32
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Owner 4F AArrchhi�itect x Contractor r
lm
Addres D` 0 &W. Y(8clfess Ad
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b&40
' not spri s., >�i iL" _ *
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Cit City_
Phone BlratNo 2mme � Phone
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I (we) the undersigned, hereby certify and acknowledge that I (we) have read the application and agree that if Curb and Gutter, and
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Paving, and/or Dedication of right of way is required by the County of Riverside, the Riverside County Department of Building and Safety
3
shall not make a Final Inspection until said requirements have been met. I am also aware that no work is to be done within the County R/W
O
without an encroachment permit. 16
NOW, therefore, it is agreed that 1 (we) will not occupy said property and will not cause said property to b occupied until IXe) have
complied with all laws of the County of Riverside and the State of California governing said property./ I.
979 Ah : f 1�1A/�s��
DATE SIGNATURE OF OWNER AND/OR AGENT _-+
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Approval by Signature from the Following Departments Listed Below �}
Must Be Obtained Prior to the Issuing of a Construction Permit. �.
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SPACE NO.
USE OF STRUCTURE
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JOB ADDRESS – SINGLE FAMILY DUPLE,/k
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LEGAL DESCRIPTION OF PROPERTTy�Y�rY — APARTMENTS AGRIC.
Lot Milt Ua<f.t 19
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-
COMMERCIAL INDUSTRIAL
14
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COMMUNITY ' Y
ALTERATIONS
NO. OF SUBMITTED PLANS ---_ USE OF PERMIT_,'%'
N Q
-
CASE NO.
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NO. OF PARKING SPACES REQUIRED N0. OF BUILDINGS NOW EXISTING -
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ZONE SETBACKS: . FRONT c� SIDE. f �� REAR
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GRADING PERMIT REQUIRED? YES n NO f® LOT SIZE
SETBACK ORDINANCE # -- OF FEET REQUIRED ONSTREET
DATE -- ! % SIGNATURE OF LA D.USE-OFFICIALy
DEDICATION REQUIRED: YES D NO ❑ NO. OF FEET--
CURB AND GUTTER REQUIRED: YES ❑ NO ' + / "�*J STREET
d
CAN CURB AND GUTTER FEASIBLY BE INSTALLED? YES ❑ NO ❑
HAS AN ACCEPTABLE APPLICATION,. BEEN MADE FOR ENCROACHMENT PERMIT FOR DRIVEWAY AND STREET
CIMPROVEMENTIMPROVEMENT;'d--440YESd--440
❑
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DATE %� / SIGNATURE OF ROAD DEPT. OFFICIAL
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9MMWMU FVULb PUBLI
SEWAGE DISPOSAL
MO
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WATER POLLUTION REMARKS
�n FLOOD CONTROL—
z AIR POLLUTION
W
W
_ DIV OF HWY
0 % - YOUR PROPERTY MAY BE SUBJECT TO
c' FLOOD. RIVERSIDE COUNTY ASSUMES
,NO RESPONSIBILITY IN EVENT OF FLOOD.
284 199 9/74 ! It,
CANARY—FILE, PINK—APPLICANT