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0105-096 (RR)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 C39 12C Date w� ! 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. S ,;) 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. STAT P_ F1.I D (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 th , wor ers' compensation prrovi5ions of'Section 3700, of the Labor Code, I sfa .ort ith%omply with those pro6visibns�" � G Date:` Applicant Warni g: ailure to secure Worker? 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, indemnity & 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 correct. I agree to comply with all City, and State laws relating to the buildil construction, and hereby authorizelrepresentatives of this City to enter yp the above-mentioned property fo;r, spection purposes. I/,,, I/ Signature (Owner/Agen't): Date BUILDING PERMIT PERMIT# DATE VALUATION LOT I}�t,AYy TRACT r ��l JOB SITE APN . ADDRESS 48-921 W"AMMWONSIRTET OWNER CONTRACTOR/DESIGNER/EN (NEER Mf C211�5f#i�lgya�AR�O�-�r�J7Y�7123Pi�� co..ry ��fr' t��iY�1Id-9014 ♦Y y 48-921 Y463�;.5.�,LCT�i;P.L0 .� ?r ,� ,�V F �y 35.9C!%.6s4�DW S, :Y4. WS, 1•V�V.%�i�S 1,A.Qt :A CA 92253 NDY-) CA 92203 (760)345-375'1 CIBL4 12 USE OF PERMIT BUILT UP R&ROOF. CLASS A. VALUATION 2509.00 L? ES M'D CCiti OF C CDARMiTO7' ON 2,5MOD RUZOOF FRE, 101.300-418.000 $3 01 0D sa =-8 M PERMU FnS DUE NOW CITY OF LA OUINTA FINANCE DEPT RECEIPT DAJE`f, BYE DATE FINALED INSPECTOR I�� INSPECTION. RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Roof Deck _� O.K. to Wrap /mac Combustion Air Exhaust Fans 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 �G�J ,��' BLOCKWALL APPROVALS Final POOLS - SPAS 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 » 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) COMMENTS: DEPARTMENT OF BUILDING & SAFETY (PERMIT NU COUNTY OF•RIVERSIDE REN. DBL. FIELD OFFICE IT91ALFEES i CONSTRUCTION ESTIMATE p CK. FE..p ++rwf ••✓��-' ELECTRICAL FEES PLUMBING FEES PLUMB. FEEy� f fi 1st FL d 2nd FI." Por. i' `ZR Raaf. * 'I Car P. I r Wali I C Sq. Ft. NO. NO. Sq. Ft. @ Sq. Ft. @ 4 It J F M M' .. J J A S 40* Sq. Ft. @ POLES IJ - F M A ,M. J J A S SIGNS DRAINAGE PIPING Sq. Ft. @ BACK LOT SIZE TRANS.�AND/ DRINKING FOUNTAIN $q. Ft. @ - 'OR T. CLK. JOB ADDRESS OWNER Sq. Ft. @ MOTOR H. P. URINAL J }/�y MOTOR H.P. WATER PIPING .� ESTIMATED VALUATION $ j' USE `OF BUIL IN - ` MOTOR H. P. FLOOR DRAIN PLAN CHECK FEE �"" j MECHANICAL FEES } MOTOR H. P. WATER SOFTENER TRICT F.C.' !t VENT SYSTEM;Lp FAN ❑ EVAP. COOL HOOD VALUATION OFFIC' MOTOR H. P. WASHER (AUTO) DISH) APPLIANCE FIXTURES O GARBAGE DISPOSAL LEGAL DESCRIPTION > 'FURNACE ❑ UNIT ❑ WALL ❑ FLOOR ❑ SUSPENDED J NU OUTLETS - LAUNDRY TRAY ~ •� Z AIR HANDLING UNIT NUf.18�f� 5 3 SUB -PANEL SPEC. INSP.- KITCHEN SINK SUPP. TO PERMIT {; O GAS PIPE ❑ NATURAL ❑ L.P.G. ❑ OILWA a TER CLOSET I . U COMPRESSOR HP I RANGE AND/OR�OVEN PLAN CHECKER LAVATORY BOND {, W APPLIANCE, VENT PLAN FILE Jt WATER HEATER INSPECTOR SHOWER It i If ABSORPTION SYSTEM D B.T.U. 0 I SPACE HEATER • BATH TUB U INCINERATOR DOMESTIC ❑ INDUS. ❑ COMM. CONSTRUCTION POLE )'WITHIN WATER HEATER THIS PERMIT SHALL BECOME VOID IF WORK IS NOT -COMMENCED 60DAY'S. CESSATION OF WORK FOR'120 .DAYS SHALL ALSO CAUSE PERMIT TO BECOME VOID. 1 HEREBY AGREE THAT ALL WORK IN CONNECTION' WITH THIS I' HEATING SYSTEM IaRORCED ❑ GRAVITY (RECEIVED BY SERVICE ENTRANCESEWAGE DISPOSAL oo BOILER D B.T.U. RESID. 10 SO. FT. dlo HOUSE SEWER •.�.��SIDE /o RESIDENTAL FEE - SO•FT.E::�@ i GARAGE iQ SO. FT. TRACTORS IS'ALSO GUARANTEED. X fj r GAS PIPING a y PERMIT FEE �""�. PERMIT FEE 1 •�'{• PERMIT FEE _"' (PERMIT NU E �� REN. DBL. IT91ALFEES �AT & E p CK. FE..p ++rwf ••✓��-' CONST. 'FE ELEC. `VwsY7yM° PLUMB. FEEy� f e./ J F M M' .. J J A S O N D IJ - F M A ,M. J J A S 0 N D BACK LOT SIZE _ UtUS�EE A JOB ADDRESS OWNER ,s++SET Is }/�y .� ZONE USE `OF BUIL IN - ` PLAN CHECK FEE �"" aw• } CHECKED BY CO U Y' TRICT F.C.' UNITS VALUATION OFFIC' MECHANICAL FEE 1 O TYPE LEGAL DESCRIPTION NU I• CONSTRUCTION FEE / 'w ~ •� 1P�RMIT NUf.18�f� 5 3 i SPEC. INSP.- SUPP. TO PERMIT f ELECTRICAL FEE PLAN CHECKER BOND $ BOND CASH PLAN FILE Jt FINAL DATE INSPECTOR PLUMBING FEE I f' TOTAL FEES )'WITHIN ... THIS PERMIT SHALL BECOME VOID IF WORK IS NOT -COMMENCED 60DAY'S. CESSATION OF WORK FOR'120 .DAYS SHALL ALSO CAUSE PERMIT TO BECOME VOID. 1 HEREBY AGREE THAT ALL WORK IN CONNECTION' WITH THIS i CASH CHECK el M.o. I I N.C. (RECEIVED BY SEWAGE SYSTEM PERMIT WILL BE DONE IN ACCORDANCE WITH THE LAWS OF RIVER- ( ;p/t T LL •.�.��SIDE /o COUNTY AND THE STATE OF CALIFORNIA. I ALSO AGREE TO CARRY COMPENSATION INSURANCE UPON MY MPLOYEES. COMPLI- ANCE WITH LAWS OF THE STATE OF CALIFORNIA COVERING CON- i I INFORMATION TRACTORS IS'ALSO GUARANTEED. X fj r a y OWNER. CONTRACTOR _"' I s ADDRE 5 I. J 4 L. NO. f ` TEL . NO. f LICENSE NO. 284-208 11/67 <,