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LICENSED CONTRACTOR DECLARATION
-f 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
\k,�4411111 �
Zate� 1,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
performance of the work for which this permit is issued.
(JC) 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.
STA113 !"(.tf+1D f 8091AMX;
(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' compens'a(ion provisions of Section 3700 of`' e Labor
Code, 1 sh II fort�'with comply with thos. provisions.
Date: ._'J ?" I `I Applicant U U11` 4' , y
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
t, e above-mentioned property for inspection p�poses.
�Signat"ure (Owner/Agent) Date NI MI
PERMIT t/ CONTROL#
BUILDING PERMIT
9702 4889
TRACT
DATE Y2R197 VALUATION S86'"Z_'� LOT 4 TRACT �;� �, 110, W141
JOB SITE S ��« bSAl�i/N,1Il)A li.l�,itMCfii4
ADDRESS
APN
77XI.45.017
OWNER
CONTRACTOR/DESIGNER/ENGINEER
llAAF }L) }:((SCS N1(t.3:,1:ti1t'��1.l:;-T('TC,1'tf.A1�1rR
P.O..BOX 72?
P.O.'BOX 7.22
I. A (XJ10 I—A CA 922;53
LAQUIN'i'A CA 972"
tGig)�G/t�Q273 L�3L1f 19;5
USE OF PERMIT
y;:1i►
WD - t4I. Gil t DOES NOT IN�,16t:61:'BL,O+ t+,'WAII'S ORPOOL
'.(' vr,, T0Na 4*RU x i0N 1,410.00 3
0A.f2 AQ1VCA1(Pr2f2 I.' 49901 !',W
C;iNAYl T ;}+"L+:C±; 8VAIhWAY
4C0I4,%J'R OCT10N f f:.h. 10 t -girl -AIR -000 $581°(X ,
_..
KAN 011l'i'C . FITF. i01-000-419-318
FEE I_m4iS111. 42506.00
N.f -'CHAb 1CAL FIX 1C1t.-000-421.000 351%
1.1— HQ I' Rf<:e1i.,1--K lot -M-4201-000 $122.83
P(,1.1NTAY40 rp-11- I ()1.00::1 t `3.(W $1.2'7.:5{)®
C" C3
,TONG f�tcyr ON tii:is - k�l . }Lz 101-000-24t-000 5.8.69
ti kW)1W- 0!7 . }tl 1-0+JCI-d23-QGQ S&60
Como
JNIf RA.9'f R1fCru131, vEa 225-1x10-443-1.1.7. 31,9<I2. r.3
� � LL.
PREPTIR FLAN 01-000-441-",345
•
fi�,yro ��yy�� ( Ap.1 l/����Y}CCvv�7�p� f//yv� pp w�,�f A �y�i t1i.
�!1"''5 �.���:itt t.J.iYw7E [�V1..3��.i �tY tslV EJ f"!�t't 1Y •*.�!'�[:1.�k1 �,.'(�;�r
�p 7 w372ry
+..r $ . 64
LESS ' RI-1'Pf`ID FLIES
-$250.00
TOTAL PY RM.IT fRXS WT NOW
53,122.62
RECEIPT
DATE
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
01,
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail 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
Final
COMMENTS:
_
Final
Utility Notice (Gas)
ELECTRICA A P OVALS
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)
TOZ-049-
P.O.. BOX 1504 APPLICATION ONLY
Building LA QOUINTA8-105 CCCALIFORNIA 92253
Address , Jul - SAO S F'6aM_1J1yP&
Owner�! n
�J� l] `CVS S 1*-�t
Mailing
AddressZ.-
City Zip Tel.
Contractor
Address
City lZip
State Lic.I City
& Classif. iSq 38 I Lic. # l S
Arch., Engr.,
Designer
Address Tel.
City I Zip I State I
� Lic. #
LICENSED CONTRACTOR'S DECLARATIC
I heyeby firm th t I amalicensed under provisions of GO-apter 9 i
D00) of Divi ion -3 Qf the 8�sfness and Professions Code%nd my
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,9usiness 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 live hundred dollars ($500).
I'JI 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, 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.)
I 1 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) licensed pursuant to the Contractor's License Law.)
11 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
0 Copy is filed with the city. ❑ 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, 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, 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
1 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 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. oOCC. GRP.
A.P. Number? :7% 3 017
Legal Description �( S OUL 1 I o, L4 j 2
Project Description
i
Sq. Ft. { C) I No. No. Dw.
Size / !! t f Stories Units
New ❑ Add O Alter ❑ Repair ❑ Demolition ❑
BUILDING DIVISION '
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
2�, 00
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
257,.)• CIO
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line {
RearrSeiback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: DateD
Validated by: FEB 19 1997
Validation:
CITY OF LA QUINTA . .
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBINGT
1ST FL. SO. FT. @ $
UNITS
HEATING (ROJGH)
2ND FL, SQ. FT.
FORMS
YARD SPKLR SYSTEM
POR. SQ. FT. @
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. @
I POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEQUIP.
DRAINAGE PIPING
CAR P. SO. FT. @
TEMP. POLE
WALL SO. FT. ¢
GROUT
DRINKING FOUNTAIN
SO. FT. @
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as,property tax valuation
=$
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
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
GAR. FIREWALL
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 11/a c
SEWAGE DISPOSAL
MESH
SQ.FT.GAR @ 3/<c
HOUSE SEWER
INSULATIONISOUND
GAS PIPING
PERMIT FEE
FINISH GRADING
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST, FEE ELECT. FEE
SMI FEEPLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROJGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GOADING
U. 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 SIGNATUAESIINITIALS
GARDEN WALL FINAL
m