0010-119 (BLCK)U)
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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 Exp. Date
425:1%} B M/3112(
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.
( )Vl'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 V Policy No.
STATE itU)4D
(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' 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. • J. . I
Signature (Owner/Agent)
Date
BUILDING PERMIT PERMT#
DATE VALUATION LOT 001k'h,.1.19 TRACT
JOB SITE APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/EN (NEER
3 OC'4r CA 92054 S t7MJ1i C& 92054
(060)967.0069 c:�.� # 1955
USE OF PERMIT
L1? X. ,5' t rA,R0*1 WAIA., - ORC>O .SYS' EM
S FT. WAI"
7.00 LF
Pr01 r FEE SUMMARY
C;ONSTRUCTION FEE 101-000418-0M 21s,00
�TJ'k8MOTM, C00MM 3-103109.A14D KdAX MUCK K $11.00
LE 33 .PRE -PAM FEES $ 0.00
TOTAL PMi :r :�} :US ME -NOW $1 x..00
RECEIPT i DATE t t* I BY I DATE FINALED I INSPECTOR
9
k
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 Backs y —O f 57_
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)
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)
.� r/c GOOD- alt
Building
Address T
T-iitt 4 QubO
4P.0 BOX 1504
MLift 78-495 CALLE TAMPICO
A�(OUINTA, CALIFORNIA 92253
'L--;.'. 5 ��
Address
City Zi Tel.
%)&
&OCs S r AFF
APPLICATION ONLY
.DING: TYPE'CONST. OCC. GRP.
Number T!J3-?4W-n2n
il Description Ltd g `�
ICt Description_, Fr '
State Ljc. City G /T �i
& Classif. ��'Z �`��, Lic. # �`t �' Sq. Ft. + No.
Arch., Engr., Size Sto
Designer
Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOR'S' LARATION
I herebLaTfign that I Iic�need under provislons of Ch er 9 (commencing with Section
7000) of Div' loM7 of th ua end Professlorla Code, a my license is in full force and
effect.
NA DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,euSiness and Professions Code: Any city or county which requires a
permit to construct, after, improve, demolish, or repair any structure, prior to4n; Issuance also
requires the applicant for Such permit to rile a signed statement that he Is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Oiviston 3 of the Business and Professions Code, or Nat. 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 ($500).
I-1 1, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Bulsness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees.
provided that such improvements are not Intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner-buBder wig have the burden
of proving that he did not build or Improve for the purpose or sale.)
I 1 I, as owner of the property, am exclusively contracting with licensed contractors to con -
the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
1-1 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
F] Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit Is for one hundred dollars ($/00) valuation
or less.)
I certify that in the performance of the work for which this permit is Issued, I shall not
employany person in any manner so as to become subject to the Workers' Compensation
Laws of Cali ornia.
Date Owner
NOTICE TO APPLICANT: ff, 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, Civli Code.)
Lender's Name
Lender's Address
This is abuilding permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I cenity that 1 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 sof this city to enter the above
mentioned properly for inspection purposes.
Signature of a0plicant -Date-
Mailing
ateMailing Address
City, State, Zip
No. Dw.
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
I PERMIT I 1A /' J I AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
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: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DMSION
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove Residential)
District, in order to determine the applicability of compatibility issues or need to require the filing of Master
Design Guidelines by the applicant. It shall be transmitted to the Building and Safety Department as your
correction list. Please attach additional explanations as necessary.
APPLICANT Pacific Trades
SITE ADDRESS 51-725 Avenida Bermudas
APN 773 _ 145 _ 020 ' BINNO.:
CASE NO.:
2000-276
LEGAL: LOT 8 BLOCK 110 UNIT S.C.@V.L.Q.
CHECKED BY: Leslie Mouriquand DATE: - - 0 (
Inform the assigned Building plan checker upon your assignment to this case. The CDD Executive
Secretary maintains a log book to track applications and assign case numbers.
REQUIRED ITEM
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COMMENT/CORRECTION
Compatibility Review
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Case logged and number assigned
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Verify legal and APN information
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Consistent with MDG on file (as.applicable
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MDG filing required (5 filings since 9/3/98)
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Consistency with street/surrounding area:
Colors
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Materials
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Architecture
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Other Requirements:
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