9803 (BLCK)4
P.O. BOX 1504
Building 49-010 BALADA CRT. 7&105 CALLS CALIFORNIAESTAD9
LA QUINTA, ORNIA 92253
Owner
JESSEEIICKEEQBR
Mailing
Address SAME
City Zip Tel.
LA QUINTA,CA 92253 564-27.52
Contractor
OWNER/BUILDER
Address
SAME
State Lic. City
& Classif. I Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I 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,Business and Professions Code:. Any city or county. which requires a
permit to construct, alter, improve, demolish, or repairany 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 Professioris Code, or that. he'is e#empt 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).
XI, 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 properly who
builds or improves thereon and who does such ,work himself or -through his own employees. -
provided that such improvements are not Inlepded ur 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.)„ .
❑ I, as' owner of the property, am exclusively coniracting 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 contractor(s) licensed pursuant to the Contractoi's-License Law.)
❑ 1 am exempt under Sec. B. & P.C. for tais.reason '
,Date I t / Owner! : 111 e� f iPJ�
WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I haveYcertificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a;c6r& ified copy thereof. (Sec. 3800, Labor Code.)
Policy No. .Company.:
Copy is filed with the city. 0r6ertified 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.) ..
1 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 t&become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, 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.
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. 3097, 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 it work thereunder is suspended for 180 days.
I certify that I have readlthis 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
No. 9903
BUILDING: TYPE CONSTBLOCK WA&&. GRP.
A.P. Number
Legal Description
Project Description BLOCK WALL 3' X BB * GARDEN
WALL
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
s
e
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: Date Permit
Validated by:
Validat
Estimated Valuation
$420.00
PERMIT
t
AMOUNT
Plan Chk.. Dep.
Plan Chk. Bal.
Const.
$15.00'
Mech.
Electrical
Plumbing
S.M.I.
87C
• U?
Grading
Driveway Enc.
Infrastructure
TOTAL
4 1.7 • U3
REMARKS
V LH)H .L i iJ 1 ML. J i:) . it J
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: Date Permit
Validated by:
Validat
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. a $
UNITS
SLAB GRADE
2ND FL. SQ. FT.
BONDING
YARD SPKLR SYSTEM
POR. SQ. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. SO. Ff. ®
GAS (ROUGH)
DRAINAGE PIPING
WALL SQ. FT. ®
OTHER APPJEOUIP.
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.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
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 I
fBATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. Fr. RESID ® 11/. c
SEWAGE DISPOSAL
SQ.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 ZLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMSS
EWER OR SEPTIC TANK
ROUGH WIRING.
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER L60P
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM Q
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
"1
CoAct ('5 ��
n
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION)OJ
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESJINITIALS
GARDEN WALL FINAL
I
J A IVA c K:
d',
5L/
X1.
-ro O -A k1-Q-lf I j-;
T Y ®F LA Q U I N TA
& SAFETY DEPARTMENT
r"J" Nr
"UCT104
AND ALL APPLICAUE
AN v�
DATE BY.!�:.
�64
ExiSTI
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LA--QU,INT
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, ItTY-bEOARTMENT
--s.Jec fOINS Tk--'- LAI' nI, Nit,
DAT
AND ALL APPLIM LCQDk%&A.'lV
i4�
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MOM
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ol
.110 1. t'5 r,
pi5-
1 eld
-T
IIVINURiANT - TH I 0 MONEY UNLESS STATEMENT IS ENCLOSED.
-STATE
HOME OFFICE SAN FRANCISCO
WORKERS' COMPENSATION ENDORSEMENT
CERTIFICATE
COMPENSATION
INSURANCE
IN CONSIDERATION OF THE PAYMENT OF THE TOTAL DEPOSIT PREMIUM AND FULL PREMIUM TO BE COMPUTED AS PROVIDED
IN THE CONTINUOUS WORKERS' COMPENSATION POLICY INDICATED HEREON, IT IS AGREED THAT
SUBJECT TO THE
D
FUND
HOF SUCTHERETO, THE EMPLOYER INDICATED HEREON IS
PROVIADDITSIONSONAL
HEREBY NAMED AS
GROUP NSURI EMPLOYER.NDNDORSEMENTS
THIS INSURANCE IS EFFECTIVE FROM DECLARATIONS
12:01-A.M., PACIFIC STANDARD TIME. CONTINUOUS POLICY 46-91
ISSUED TO
3-09-91 TO 1-01-92 AND SHALL WESTERN REGIONAL MASTER BUILDERS
AUTOMATICALLY RENEW EACH 1-01 ASSOCIATION
UNTIL CANCELLED
UNIT
3172
R. BOYD CONSTRUCTION DEPOSIT PREMIUM
$2,611.00
44-758 RUBIDOUX
INDIO, CALIF 92201 MINIMUM PREMIUM
$520.00
PREMIUM ADJUSTMENT PERIOD
MONTHLY
REP 01
N SK
NAME OF EMPLOYER- RICK BOYD
AN INDIVIDUAL EMPLOYER AND NOT
JOINTLY WITH ANY OTHER EMPLOYER
TRADE NAMES- R. BOYD CONSTRUCTION
B559154
LOCATIONS- 44-758 RUBIDOUX, INDIO, CA 92201
1. WORKERS' COMPENSATION INSURANCE - PART ONE OF THIS POLICY APPLIES TO THE
WORKERS' COMPENSATION TAWS OF THE STATE OF CALIFORNIA.
2. EMPLOYER'S LIABILITY INSURANCE - PART TWO OF THIS POLICY APPLIES TO
LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE•LIMIT OF OUR
LIABILITY UNDER PART TWO IS,
$3,000,000
CODE NO. PRINCIPAL WORK AND RATES EFFECTIVE TO 1-01-92
BUILDING CONSTRUCTION --
SEE ATTACHED SCHEDULE FORM 10500
TOTAL ESTIMATED ANNUAL PREMIUM $13,056
1-91
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO MARCH 19, 1991 POLICY FORM K 1L
SCIF FORM 10241 (REV. 7-64) (OVER PLEASE)
OLD DP 241
• REP 01
f, STATE 046-92-0003172
COMPENSATION RENEWAL
IN SU:ftANCE SK
FUND
HOME OFFICE ENDORSEMENT AGREEMENT
SAN FRANCISCO EFFECTIVE -MARCH 9, 1992 AT 12.01 A.M.
ALL EFFECTIVE DATES ARE
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
R.-BOYD CONSTRUCTION
44-758 RUBIDOUX
INDIO, CA 92201
ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS
AGREED THAT THE WORDING FOR THE FOLLOWING CLASSIFICATION APPEARING
I1.; THIS POLICY IS CHANGED TO READ -
SEE CONS SCHEDULE ATTACHED
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: DECEMBER 20, 1991
If -%' W"- 9904
AV THORIZED REPRESENTATIVE PRESIDENT
SCIF IRM 10217 (REV.7-84) OLD DP 217
Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions
agreements or limitations of the Policy other than as herein stated.
When countersigned by a duly authorized officer or representative of the State Compensation Insurance
Fund, these declarations shall be valid and form par-. of the Policy.
AUTHORIZED REPRESENTATIVE PRESIDENT
i
If you have any questions, please contact your local State Fund Office below:
Riverside District Office
6147 River Crest Drive
Riverside, CA 92507
Telephone No. (714) 656-8300
J
Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions
agreements or limitations of the Policy other than as herein stated.
When countersigned by a duly authorized officer or representative of the State Compensation Insurance
Fund, these declarations shall be valid and form part of the Policy.
AUTHORIZED REPRESENTATIVE PRESIDENT
1
If you have any questions, please contact your local State Fund Office below:
Riverside District Office-
6147
ffice"6147 River Crest Drive
Riverside, CA 92507
Telephone No. (714) 656-8300