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LICENSED CONTRACTOR DECLARATION '
Wiereby 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
537333 A B 8/31M
ignature 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.
( ) I have and will maintain workers' compensatlon 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 STATE FUND 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: s I �r� lsn-pplicani C
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.
vSignature (Owner/Agent) `��'»=�-�''-"' Dated 1�-�
__ _ - f
BUILDING PERMIT PERMIT
DATE 1.911.3193 VALUATION SJ,.W.00 LOT TRACT
JOB SITE 51-725 AVEN1.DA VILLA
APN 7?3-143 023
ADDRESS
OWNER
CONTRACTOR / DESIGNER /ENGINEER
��'yy �'YYrypTF(rp
EV la l N 11 L. ",. YU1L,L
li' IUM, 81 L, ,SNC.
PO i3CiX 147
P.O. 113ON,,1S55
LA CSE INTA CA 92253
f .A 4CJI1ti TA CA 91253
(76.+0)340-2726 CAL# 2520
USE OF PERMIT
PLUMBING
iWraia+ia.: S OMOILOCaTIRMiaa'<4
!,€ltfil.tJll
P ERi U a PER S,64141ARY
PLUNIBINt3 FFE -- SHWE k 1.01.-000-4:19-K0 530.00
NOV .13.1998
s C
$30.00
LESS 1'1ts"?.TAID FEES
$0.00
TOTAL PE'R.M.C.Ir IMPS OU&NOW
S30-00
A
RECEIPT
DATE
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 8 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
Underground PI . 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:
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
K. " RA5"t �
G.A. Code
f
❑ Py to: L
L.
Received From:J-
Address: r '' C, 1
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Account No. ��=' )�� E •'i Ll 7 �� '
�) •[) Lot(s)
Check'
Service Address �'� l- �' r
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Money
t
❑ Meter(s)
Cashier .�
Order
''
❑ Service(s)
st
. .. ❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
a Meter Surcharge
D -Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract`-.'
Fee -
❑ Plan Check Fees Water I Sewer -
Tract - '
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
Remarks:. -
K. " RA5"t �
G.A. Code
f
❑ Py to: L
L.
Cash
=-
Water service
Check'
Money
t
t
Cashier .�
Order
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CVWD -438(11/89)
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PUMPING 51: Vick 2502 Morongo Trail
Palm Springs, CA 92264Q
(760) 327-8859
SOLD TO
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TERMS
SNIPPED TO
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STREET NO.
ST/ATTEE
STREET NO.
C I T
STATE Z I,P_ _
CITY STATE ZIP
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CUS�ER ORDER
S LESMAN
TERMS
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PAYMENT DUE�UPON.RECEIPT .
Building � v/ _ 7,2 7 11; ll '
Address
Owner
y-e IL,K H. -t-,6;
'Mailing / / y
Address
S rr r!J r S
CityZip Tel.
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Contractor
P.O. BOX 1504 , _ APPLICATION ONLY
. 70'105 CALLS ESTADO ..
LA QUINTA, CALIFORNIA 92253
BUILDING:' TYPE CONST. • OCC. GRP.
A.P. Number
7 Legal Description
Project Description
�7%'3`/0 73oc.4,Al Ae•
City " g Zip Tel..
�/'wk-/6fta �itc .s _rl
State Lic. City
& Classif. Lic. # Sq. Ft. No. No. Dw.
Size Stories Units
Arch., Engr.,
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel. / "r r r
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need -not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: If, alter 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, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I 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 -of this city to • enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address _
City, State, Zip
BUILDING DIVISION
REMARKS
r&
` AMOUNT
j
City
Zip
State
Lic. #
Minimum Setback Distances:
LICENSED CONTRACTOR'S DECLARATION
Front Setback from Center Line
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.
1
Rear Setback from Rear Prop.. Line
SIGNATURE DATE
-
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason; (Sec. 7031.5,13usiness and Pro/essions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section. 7000) of
Estimated Valuation
PERMIT
Division 3 of the Business and Professions Code, or thathe is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
Plan Chk. Dep.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
I7 I, as owner of the property, or my employees with wages as their sole compensation, will
Plan Chk. Bal.
Const.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
Mech.
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
Electrical
orimprovement 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.)
Plumbing
I.1 I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct 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
S.M.I.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
17 I am exempt under Sec. B. & P.C. for this reason
Grading
Driveway Enc.
Date Owner
Infrastructure
WORKERS' COMPENSATION DECLARATION
I hereby affirm that -I 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
❑ Copy is filed with the city. O Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need -not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: If, alter 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, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I 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 -of this city to • enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address _
City, State, Zip
BUILDING DIVISION
REMARKS
r&
` AMOUNT
j
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:
CONSTRUCTION ESTIMATE NO, ELECTRICAL FEES NO. PLUMBING`FEES
1ST FL SO. FT. rd $
2ND FL. SO. FT, tryry.
POR. SO. FT. n
GAR. Sp, FT,
CAR P. SO. FT.
WALL SO. FT.
SO. FT. ®
ESTIMATED CONSTRUCTION VALUATION S
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
F
FLOOR DRAIN
MECHANICAL FEES
BONDING
WATER SOFTENER
STORAGE TANK
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
ROUGH WIRING
APPLIANCE DRYER
ROCK STORAGE
GARBAGE DISPOSAL
GAS (ROUGH)
FURNACE UNIT WALL FLOOR SUSPENDED
HEATING (FINAL)
LAUNDRY TRAY
REINF. STEEL
AIR HANDLING UNIT CFM
I
KITCHEN SINK
ABSORPTION SYSTEM. B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
FINAL INSP.
COMPRESSOR HP
POLE, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. @ c
BATH TUB
ROOFING
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 1'A c
SEWAGE DISPOSAL
SO.FT.GAR @ 3/ac
HOUSE SEWER
FIRE ZONE ROOFING
FIREPLACE
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
•i e
MESH
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE 114ROUGH
PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
' ]
BOND BEAM / /�
WATER SYSTEM
GRADING
cu. yd.
g
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION ►�,�
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
-