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9606-144 (DSF)T LICENSED CONTRACTOR DECLARATION PERMIT# CONTROL# U) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 96]]1ft-144 3583 I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE TRACT 1%VALUATION j,) N w Professionals Code, and my License is in full force and effect. O :) ch License # Lic. Class Exp. Date Ci LO51;W 67 .13 MV97 JOB SITE ADDRESS 4�LM AVEMDA K, PO4MDO APN .631-35Z_IXM W -+. rti� `�/ , !�� (it jG h OWNER CONTRACTOR/DESIGNER/ENGINEER � Z ^/Date Signature of ContractorL � • � j:Z °) OWNER -BUILDER DECLARATION J0 ll%1 A & NINVt [fit 1�'lII ll' JACK CLAR K'Cf'.Nt? .Al.. i.ON11'[�.AC M) 492N.A.V041DA. FERiv: NDO ' 54 -31St) AVERIDA HkiR,R.]"sR A- Wco O_ I hereby affirm under penalty of perjury that I am exempt from the Contractor's COACHE 4,A CA 512236 LA. OU1NTA CA 92251 Cn License Law for the following reason: Z_ ( ) 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). USE OF PERMIT ( ) I, as owner of the property, am exclusively contracting with licensed 1`t1Vi(j. j�fij contractors to construct the project (Sec. 7044, Business & Professionals Code). t'') O I am exempt under Section B&P.C. for this reason DEMOL1 XiON LO N Date Signature of Owner O N rn Q WORKER'S COMPENSATION DECLARATION o Z I hereby affirm under penalty of perjury 'one of the following declarations: F- O () 1 have and will maintain a certificate of consent to self -insure for workers' X W �= compensation, as provided for by Section 3700 of the Labor Code, for the O � Q performance of the work for which this permit is issued. m Q C) ( ) I have and will maintain workers' compensation insurance, as required by O U Section 37,OO,koef�.,the Labor Code„for the performance of the work for which this Z permit isJi siJetlrPAY l-'HworkV� 11ompensation insurance carrier &policy no. are:�� ' �'� 1 4 -ax is i].i�{� Carrier Policy No. 1".N;.i3i19IT FEE' StI MARY cb 53rfvfa].i�rar�.r tt)J34]09 J (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 UID workers' compensation laws of California, and agree that if I should become CO7 subjggEt to the workers' compensation provisions of Section• 3100 of the' Labor 07 C96e, I s �I�fo �h�withAomPly arit-�hil�G.;'�.those provt...,�El%�:./;� pate: �” _ PP VV ` Warning: Failure to secure Workers' Compensation coverage is unlawful and f Q( shall subject an employer to criminal penalties and civil fines up to $1.00,000,.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 SLM-TOTAL CONS J lt.UC t YON AND F'"WMMCK �'=5 whose request and for whose benefit work is performed under or pursuant to LESS -J PLE-.PAID FRES $0.00 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. PERMIT FRES. DUE+, 9V0%V 2. Any permit issued as a result of this application becomes null and void if 1TflLf ` 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 f l the bove-mentioned property for inspection purposes. _ J RECEIPT DATE ,Y DATE FINALED INSPECTOR ignature (Owner/Agent•)f`te'1. C. �`.irrll.'1r"'r� Date4 '-Y"` f�* xx '� N. 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 Wali Insulation Condensate Lines Party Wali Firewall Exterior Lath Drywall - Int. Lath Final Final / POOLS - SPAS BLOCKWALL APPROV S 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) 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) ` 1 NOTICE: THIS IS NOT A BU11L0ING,QERMIT DISTRICT �+> APPLICATION TO CONSTRUCT Permit No DEPARTMENT OF BUILDING AND SAFETY COUNTY OF RIVERSIDE !P ♦ 284 199 9/74 CANARY—FILE, PINK—APPLICANT Ownerfjrchitect Contractor Addres �dres Address74/22Z el Cir City City- --��''// Phone; - �- Phone Phone of tZW I (we) the undersigned, hereby certify and acknowledge that I (we) have read the application and agree that if Curb and Gutter, and Paving, and/or Dedication of right of way is required by the County of Riverside, the Riverside County Department of Building and Safety 3 shall not make a Final Inspection until said requirements have been met. I am also aware that no work is to be done within the County R/W O without an encroachment permit. NOW, therefore, it is agreed that I (we) will not occupy said property and will not cause said property be occupied until I (we) have complied with all la s of the County of Riverside and the State of California governing said property. DATE SIGNATURE OF OWNER AND/OR AGEN Approval by Signature from the Following Departments Listed Below Must Be Obtained Prior to the Issuing of a Construction Permit. I SPACE NO. 1 USE OF STRUCTURE ` JOB ADDRESS _Ail=! SINGLE FAMILY M DUPLEX LEGAL DESCRIPTION OF PROPERTY - APARTMENTS AGRIC. [] OW / ' / �� / `� H Q a� ��� COMMERCIAL INDUSTRIAL [� COMMUNITY.- ALTERATIONS ❑ Z NO. OF SUBMITTED*PLANS - USE OF PERMIT us N Q CASE NO. NO. OF PARKING SPACES REQUIRED NO. OF BUILDINGS NO 'XISTING -- G Z JJ ZONE SETBACKS: FRONT 5..,~ —SIDE -REAR m �/ GRADING PERMIT REQUIRED? YES ❑ NO ❑ LOT SIZE SETBACK ORDINANCE # _— OF FEET REQUIRED ON STREET DATE SIGNATURE OF LAND USE OFFICIAL —_ F, DEDICATION REQUIRED: YES ❑ . NO ❑ NO. OF FEET - CURB AND GUTTER REQUIRED: YES ❑ NO ❑ STREET v CAN CURB AND GUTTER FEASIBLY BE INSTALLED? YES ❑ NO ❑ W HAS AN ACCEPTABLE APPLICATION BEEN MADE FOR ENCROACHMENT PERMIT FOR DRIVEWAY AND STREET 0 O IMPROVEMENT? YES [INO ❑ °L DATE— SIGNATURE OF ROAD DEPT. OFFICIAI SWIMMING POOLS PUBLIC H d SEWAGE DISPOSAL _ FOOD ESTABLISHMENT WATER POLLUTION REMARKS r�t FLOOD CONTROL AIR POLLUTION W z DIV OF HWY JYOUR c PROPERTY — MAY BE SUBJECT TO o. c FLOOD. RIVERSIDE COUNTY ASSUMES NO RESPONSIBILITY IN EVENT OF FLOOD. 284 199 9/74 CANARY—FILE, PINK—APPLICANT DEPARTMENT OF BUILDING AND SAFETY COUNTM OF RIVERSIDE APPLICATION CERTIFICATE PERMIT N Effective July 1, 1980, Chapter 1301 Section 19823 'of th& R"I th and Safety Code requires the execu- tion of the following applicable declarations prior to the issuance of a building permit. Please -print'or type .and sign below: 0 LICENSED CONTRACTORS 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. License Class r License No. , c,f, u,S/f Date //:- i'7— Contractor _ /�J• J �.rra.-�..0-7 Q OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reasons: 0 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. If I sell within one year of completion, I understand I will have the burden of proving I did not build or improve for.the purpose of sale (Sec. 7031.5;'6.&P.C.). [� I. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, B.&P.C.). Q I am exempt under Section , B.&P.C. for this reason: Date Owner L] WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure or a Certificate of Workers' Compensation Insurance, or a certified copy thereof'(Sec. 3800, Lali�/Co�� Policy No. Insurance �� Q, Certified copy is hereby furnished. Certified copy is filed with the County ofii�rside, epartmenti of B it ing and Safety. Date /Y— / 7 "'�d Applicant /` `�ii� d?� Q CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if 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. I further understand that if after making this Certificate of Exemption, I should become subject to the Workers' Compensation provisions of the labor code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Date Applicant 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. Code). Lender's Name Lender's Address DIVISION OF INDUSTRIAL -SAFETY PERMIT CERTIFICATION I hereby certify that no excavation five (5) or more feet in depth into which a person is re- quired to descend, will be made iri connection with work authorized by this permit, and that no building, structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8, C.A.C.) 0 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from that division. 0 Division of Industrial Safety Permit No. Date _ _ __Applicant_ 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 construction, and authorize a representative of the County of Riverside, Department of Building and Safety to enter upon the pro- perty for which I have applied for this permit for the purpose of making inspections. Signature of Applicant/Agent Date PrintApplicant/Agent Name 284-2000 7/80 of the Desert ' f� s' B ,r Sir° ; ` !✓`�4�` .f �`�y �i� � , e, i • 7-' y ep Il ae IA Q, 4 fZ r / J 1 a f , • � I vll + � O 4� \ 0 ✓ LU a � ,00. > Z a CL a r3 Dil IINNIIL.•roN SAL -F,' 'COMPANY � ''' 1 73626 Iligl+u: