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0402-061 (RER)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions bsf Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. L&ense'# Lic. Class Exp. Date ej'� 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). / % f ( ) I am exempt under Section i3&P.C/for this reason/ Date �,T,.�2t T, - �a% Signature of Owne �;".._ '14, WORKER'S COMPENSATION4 DECLARATION I hereby -affirm under penalty of perjury one of the following declarations: () I •fiave 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 stall 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: pplicant Warning: Failure to secure Workers' Compens (on 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 repr 7entatives of this City to enter upon the above-mentioned propertyfor/inspection purposes. Signature (Owner/Agent) " 7Date � r PERMIT# - - - BUILDING PERMIT fW024KI _ DATE'S LO,T _ c i s -•TRACT.. VALUATION ., -JOB ' SITE ADDRESS 7—.�. �`.L11"f.�TA WYER�.KO APN OWNER CONTRACTOR/DESIGNER/EN (NEER AV h1b'.WA ffE.''T11 J//1. t. A r 1 = '' . t' iWNERJi3Li tt11�Ep 77-224 CAL1.E:F{)MRO ' r LA QUI14 A CA 92253 r f "Je- „fJ' USE OF PERMIT KITCHZN ".11110D ;lr PZR APPROVED PI—A14S. 2001 C8 C. CONTMOT ,MOUNT 4;0DOM IS u. Corr or i:®mmuc-moN 4AMM. PEIMM PAP S[.f MAIRY CONSTRUCTION }EE 101-000.418-000 $63.00 P1,A14 CHECK FE -41 101-000-x.19-318. $669.67 d i.Efr"1 ICAL;FER 10.1-000•-420-000 $54.00 PLUN0INO IlIT, 101 -0%' $21,00 STRONG MOTION IrNR� - R2.. ,K) 101 -000 -211 -Orifi �3 Tri-TC17°RL �t)1�`.�r f7€` i©Al t�1�9 PLAkd CIE(CC. $226.67 LP -33 PILE -PAID HIM MOO U' F1fR_NnTFYTNDdE.N0W r MAR 2 2.2004 CITY,OF LA IN aA '--........... FINANCE D RECEIPT �� - 4 BY ---- DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric b Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) c ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: A x Bin # Ci of La�$uinn'- City Building aL Safery Division P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Petmt # C/7 Project Address: 7 7 ZZL/ Owner's Name: A. P. Number: Address: 772Zyl/� Legal Description: Eotrera Mr.- -uL_ City. ST, Zip: FTelephone no -6 Address: /Lf I10 D Project Description: ,%� j a/n City, ST, Zip: 1-4-_ &4- 4? Z Telephon(7G 0) : �r ;_r, = T,X: • /// / - State Lic. # : City Lic. #: Arch., Engr., Designer •e•S j t� a Address: City, ST, Zip: Telephone: .'. - Construction Type: U / Occupancy: IZ State Lic. #: Project type (circle one): New Add'n Alter Repair Demo Name of Contact Person: Sq. Ft.: # Sto •es: # Units: Telephone # of Contact Person: rEstimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd R'ee'd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Cales. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person tfr-j Plan Check Balance Energy Cales. Plans Picked up 0 Construction • Flood plain plan Grading plan Plans resubmitted 2'' Review, ready for correctio tune 3 p M1lechanical • Electrical • Subcontactor List Called Contact Person Plumbing • Grant Deed Plans picked up SAI.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- 3" Review, ready for corrections issue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees E L Total Permit Fees �7- � �� COW (Y/O 3�/g S+ -r v t --t %D Q L K P� r o �Q b l-� CITY OF LA QUINTA SUB-C;OIVTRACTOR LIST JOB ADDRESS '24 ( !�"' PERMIT NUMBER e9Z- 061 OWNER oe✓i✓A- 5f577GR DY A'y BUILDER This form shall be posted on the job with the Buil dirz g Inspection Card at all times in a conspicuous-plaee. Only persons appearirg,on this list or their employees are authorize o� s, this job. Any changes to this list must be approved by the Building Division prior to commencelmerit ,of work.'Failure to com ly will result in a stoppage of work and/or the vo nce of building permit. For each applicable trade, all information requested helnw mist hp r-tmmplatori hu .�nnlirant n �ae11 ;� - .- ------ ------ ------ -- --...r-.,-.,... ..� �. �.. r........ ... i .... � � Trade / Classification Contractor' "WL U" U%,%,VpLGU1G IGJjJV117C. State Contractor's License `IlVorkers Compensation Insurance 'u "'' `04 City Business License EARTHWORK IC -12) IC -81 -Company Name klA Classification. (e.g. A, B, C 81 License Number Ixxxxxxl r— j Exp. Date S{ Carrier Name ` (xx/xx/xx) (e.g. State Fund, CalComp) I�CONCRETE Policy Number (Format Varies) Exp. Date lux/xx/xx) License Number (xxxx) Exp. Date (xx/xx/xx) FRAMING (C-5) STRUCT. STEEL (C-51) N O. 1 MASONRY (C-29) NIX I �" -_.t 71911?► L4 CR 64 Ct yt �•F ���-� %-30 I' , l�1mLetud'0o 4X tg 6%111 %�b 16bi 0 11 b'��� of o (JQz'�joloqN 6C)32J� �a oaf PLUMBING (C-36) t�i�/�iP�IL' - 1 C-to/I tG C'3 LATH, PLASTER (C-35) N/A DRYWALL (C-9) HVAC (C -20)N - 14 ELECTRICAL (C-10) ROOFING (C-39) SHEET METAL (C-43) �io>= r4kiL C7i'IIV�P NIA, FLOORING (C-15) NIA GLAZING (C-17) INSULATION (C-2)��E� l SEWAGE DISP. (C-42) PAINTING IC -33) OW CERAMIC TILE (C-54)— CABINETS IC -6) pWNF—:r _ � FENCING IC -13) NIA I. LANDSCAPING (C-27) N (Or ` POOL (C-53) 6K C— v<< C 6; OWNER/BUILDER INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/ Builder," you are the responsible party of record on such a permit. Building permits are riot required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by law' to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the -State and Federal Government as an employer and you are subject to several obligations including State and Federal income tax withholding, federal social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to worker's compensation insurance. For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N. Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-4 Calle Tampico La Ouinta, CA 92253 'S SIGNATURE/DATE PROPERTY ADDRESS PERMIT NUMBER(s) ... , ,. �..:- .... ,. .I .... ..: .. ... .. .. .: ... , ,.. ., _;... rcmmji nrrLWnrrun .. .... _ .. - ' County of • Department of Building Riverside and Safety 4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880'N. SI'ate Stet 227 North "D" Street 46-209 Oasis St. Rm. 310 160 N. Broadway Riverside. CA 92501 Banning, CA 92220 Hemet, CA 92343 Perris, CA 92370 Indio, CA 92201 Blythe, CA 92225 Ph: 787-6146 Ph: 849-7312 Ph: 658-4464 Ph: 657-3898 Ph: 342.8271 Ph: 922.2670 This.permit becomes void it work not commenced within 180 days Irom date o1 issuance. OR, if work has been suspended or abandoned for a period of 180 days. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if the with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. permit is for one hundred ($100) or less. I certify that in the performance of the work for which this permit is issued. I' r shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. License Class Lit. Number • Date Applicant Date Contractor NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should become subject to the Workers' OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the :allowing Compensation provisions of the Labor Cade. you must forthwith comply with such provisions or this permit shall be reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter, deemed revoked. improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be with Section 7000) o1 Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for Any Section 7031.5 by for the -applicant to a made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition dismantling thereof, be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8. the alleged exemption. violation of any applicant a permit subjects civil penally of not more than five hundred dollars ($500).): or will C.A.C.) as owner of the property. or my employees with wages as their sole compensation, will do the work, and the ❑ As owner -builder. I will not employ anyone to do work which would require a permit from the Division of Industrial has from division. yI, ucture is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law Safety, as noted above, unless such person a permit to do such work that does not apply to an owner of property who builds or improves thereon, and who does such work himself or through ❑ Division of Industrial Safety Permit No. _ his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Date Applicant 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.). 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, Civ. C.). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Lender's Name ' usiness 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 Lender's Address License Law.). I certify that I have read this application and state that the above information is correct. I agree to comply with all e m exempt under Sec. . 8, 8 P C (Attach Certificate). city and county ordinances and state laws relating to building construction, and hereby authorize representatives of y� �' Doh a,, ... /i ;.w > Ownerj� f._v`'• ,(r, .___.. this county to enter upon the above-mentioned property for inspection purposes. f'• f,L J "' �% m/Ja „✓ WORKERS' COMPENSATION DECLARATION: I hereby affirm That I have a certificate of consent to sell -insure, ora - .1�x t`J .-�P"., :✓X� j ,✓dam ""'r� / " !Signature of Pp liliant or*Agent Date certificate of Workers' Compensation Insurance, or ecertified copy thereof (Sec. 3800, Lab. C.). CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that the information given is correct. I agree to comply with all state laws and county ordinances relating to building con. Policy No. Company struction. and authorize a representative of the County of Riverside. Department of Building and Safety to enter upon Certified co is herebyfurnished: the properly for which.) have:apDlietl%or phis, permit forthe purpose of making inspections. p ., Certified copy is filed with'the County Building Inspection Department or County Department. -"' Signature of. A MEantrorrAllenf"^"'y'-"-" Date ` Date Applicant Print Applicant/Agent Name APPLICANT NAME (L, F. MI) APPL/PRMT n PS DATE,- 00 � 1187 r i / .r f ADDRES _ , CITY/COMMUNITY/STATE/ZIP JOB SITE ADDRESS/SPACE 7 7 _ ? -? - V n _41 t 9-= Pn ►1,= C� ('_)i LBOK f I PAG , I PRC I C I TWN I RNG I SES TRACT I- COT MOD SB TRACT NAME r OWNER -NAME (L, F. MI) P ADDRESS • 1 CITY/COMMUNITY/STATE/ZIP ' PHONE a LICNC p - v ARC/ENG FIRM NAME ADDRESS PHONE a LICNC N USE OF PERMIT, r,,,.,• - f' _ iVli BL ZON r . FSB I SSB I SSB I L'RSB OFC ZONE ORD 4' LOT SZ END SIDE. C, a{ , • � _'" .�lf! •mel t r t • t 4 TOTAL FEE /• 001187 i NO. OPERATION DATE INSPECTOR NO. OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS 1 Set Bock 33 Ventilation System 2 Ftgs & Frms 34 Plenums & Ducts 2A Slab Grade 35 Furnace Comport. 3 Steel 36 Inlets & Outlets 4 Grout Blocks 37 Combustion Air 5 Bond Beams 38 Compressor 6 Roof Deck 39 Appl. Clearance 7 Framing. 40 Fire Damper 8 Vents 41 Smoke Detection Device 9 Garage Fire Wall 42 Commercial Hood 10 Fireplace P. L. 43 Final 10A Fireplace T. 0. °O. ------------ ------------------------------------------------ ADDITIONAL INFORMATION' , ------------------------------_-15 SEWAGE SYSTEM SIZE & LOCATION 11 Exterior Lath 12 Internal Lath 12A Drywall 13 Finish' Grade INSULATION Thick ' R Valve 7A Walls (Batts) ' 12B Ceiling (Batts) ' 12C Ceiling (Blown) 14 1 Final _----------------- PLUMBING- APPROVALS --------------- 15Ground Plumb 16 Water Piping 17 Rough Plumb 18 Vents 19 Sewage Disposal t —Sri 20 Sewer 21 Water Heater 22 Water Softener 23 Water Service 24 Gas Test 25 Final _ _ Tank Pit L. Line OF PROPERTY LINE ELECTRICAL APPROVALS P/N �E~!C • P/ 26 Power Pole 27 Conduit 28 Service Entrance 29 Wiring 29A Grounding Wire 29B Bonding 30 Fixtures 31 Service 32 Final I STREET NAME X_ _