0310-100 (BLCK)LICENSED CONTRACTOR DECLARATION
!'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
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that1 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 lid6hg6d
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section , B&P.Ce-for this r ason
DateI,�ir, Signature of Owner i.r�tVtsa (moi1�`i^"tr7F�:=
i-1---G.�. a
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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with(those provisions.-^� �}
'Date: r,+ Applicant 0�,Ar.dht.I
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 '�,� r
Signature (Owner/Agent).1— t*"`irJ t @ XNtf9/%3YJ1Date !_`f
BUILDING PERMIT PERMIT Jt
DATE VALUATION LOTSd��l TRACT
JOB SITE
ADDRESS "YStOC�
qpN
2t�h6,1➢ 076. -IMS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
RICHARD AMOPIWO
OWMR BURZER
50.85 CAVI RONDID
LAQI.1I",d''A CA 02253
(? d C13L
USE OF PERMIT
OENnAL BIX DING
16 L..'?. 0HIUMBLOCN7 WALL. ENCLO311RE �' C
6 FT1 WALL 16.60 IX
1z:'s"TI1 91119 13 CMM OF COM711IRTI .0N
�3t1iD.i�t�
COMPU TION FEE 101-000-418-000
SUB -TOTAL C0X3T.?.r. Cr1r0- X MD PLAN CIE=
LESS PRE -P , 4I1_)TXS
$0,00
L,=J
D
DIN NOW
$15.00
OCT 09203
CITY OF LA QUINTA
FINANCE DEPT. 10/4/ot
RECEIPT
DATE r,
(9
BY'• %
By
DATE FINALED
INSPECTOR
� � � •
INSPECTION RECORD
O ERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPRO S
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 K
POOLS - SPAS
BLOCKWALL APPROVAL
steel
Set Backs
EI is Bond
Footings
in Drain
Bond Beam/Approval
to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Npater Final
Water Piping
PI bing Final
Plumbing Top Out
Equi ent Enclosure
Shower Paris
O.K f Finish Plaster
Sewer Lateral
Pool CoNr
Sewer Connection
Encapsul ' n
Gas Piping
Gas Test
Appliances
Final
COMMENTS.
/
IftA���V, v
�N�G��+7H � •�1,����
Final
Utility Notice (Gas)
E CTRICAL APPROVALS
Temp. Power P
Undergrou onduit
Rough W
Low Voftd& Wiring
Fixtures
Allain Service—
Sub Panels .
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504 BUILDING & SAFETY DEPARTMENT
78-495 CALLE TAMPICO (760) 777-7012
LAQUINTA, CALIFORNIA 92253 FAX (760) 777-7011
April 7, 2004
Mr. Richard Moreno
50825 Calle Rondo
La Quinta, CA 92253
RE: Building Permit Extension Request — 50825 Calle Rondo. .
Dear Mr. Moreno:
I have received your letter dated April 7, 2004, requesting an extension for the
masonry wall propane tank enclosure being constructed at the above address
under Building Permit #0310-100.
Permit status:
Permit issued: 10/9/03
180 -day expiration date: 4/6/04
180 -day extension date: 10/4/04
Under the provision's -of California Building Code. Section 106.4.4, your request
is hereby granted.
.Because the Building Code specifies that "no permit shall be extended more than
once," please be advised that unless the project passes its next required
inspection on or before Monday, October 4, 2004, your building permit will
expire automatically. -
Your -truly,.
Greg Butler
Building & Safety Manager
a, '
April 7, 2004
Attn: Mr. Greg Butler -Building & Safety Manager
City of La Quinta Building & Safety Department
78495 Calle Tampico
La Quinta, Ca. 92253-1504
Re: Yard Wall for The Residence of:
Mr. & Mrs. Richard A. Moreno
50-825 Calle Rondo
La Quinta, Ca. 92253
This letter is to document a request for a concrete block wall permit extension per
Mr. & Mrs. Richard A. Moreno. Please contact me with any questions.
Sincerely,
RichardA. Moreno.
31 cit- /oo