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0105-275 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of _,C hapler 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 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 & Prof essionals•Code). ( ) I, ' a's owner of the property, am exclusively_ contracting with licensed contractors to construct the project (Sec. 7044, Business & Protessionals Code). r ( am exempt under Section B&P C. for this reason ate x,; x -y;, a-, ,! --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' 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 kvisions= Date'. 6-1 ,�✓aA'pplicant:. 'tl : .' r `. ✓ 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 fo inspection purposes Signature. (9wne._1_..t) - ''/� �*�� " `.Date V,L BUILDING PERMIT PERMIT# DATE )O^. ', "� VALUATION LOT d��,® - I,;j TRACT JOB SITE APN ADDRESS 24W At6:MMitL' 'MA. W OWNER CONTRACTOR/DESIGNER/EN (NEER JIM LVALK . 5, 2•4C10,MMilaAWLT.A. 52-400 AVENIDA.I 1.4, Quiar-4 CA 9_7253 LA, )j13'N'A C".A. 92253 (760)'66A-2808 +CBLO USE OF PERMIT �.Y?��r':31',i,�F��. �t�.11 L6.7Y'f�{6:i• ✓ tb i—F. Or RIPMWOOn FMC19 - n" k40H AT SME Y AT%,V. CITY 617`x. WOOD hEWOE 16.0 U? MUM COMP OF CON91RUEM10IN YERMT ,"M SUMMMY i~ONS'i'RUC3`bON Ms, 101-000 418-000_ , . S.1 N) n O M Ail 2 3 zoos A CI Of , FINANCE DEPT 47Or-s-8OlAL C%.) 1YJRUla P 011.AWD AL7Si �.....7:iLiiA-X SM IMS .PRE -Y -''d MIS $0100 RECEIP} DATEBY DAT FINALED INSPECTOR tri INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR ' BUILDING APPROVALS MECHANICAL APPROVALS ;Set Backs Underground Ducts 'Forms & Footings Ducts 'ISlab Grade Return Air ISteel i�, Combustion Air ,Roof Deck, Exhaust Fans (,O.K. to;Wrap F.A.U. -IFraminli Compressor llnsulation 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 POOLS - SPAS {. BLOCKWALL APPROVALS steel ;Set Backs Electric Bond Footings -O Main Drain Main !Bond Beam Approval to Cover Equipment Location Underground Electric # Final ��0 S'% Underground Pibg. Test Gas Piping PLUMBINGAPPROVALS 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) • P.O. BOX 1504 APPLICATION ONLY Building 78-105 CALLE ESTADO Address LA.QUINTA, CALIFORNIA 92253, Owner BUILDING: TYPE CONST. OCC. GRP. Mailing _ Address �• UX� A.P. Number %� 3 2/'GG7 Zip _17�F7t/__ 7?5�City��lr6. Legal Description Contractor Project Description Address /* «- . City Zip Tel.. State Lic.City & Classif. �5'3 Lic. # Sq. Ft. No. No. Dw.: , Size Stories - Units Arch'., Engr., Designer / New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Address Tel. b - City Zip / State Lic. # / LICENSED CONTRACTOR'S DEPtARATION I hereby affirm J6 l am licensedd ynder/provisions f Chapter 9 (commencing with Section 7000) of Division'3 of the Bu inessrand Professi ns ode, and l license is in f (I fo ce and effect. DATE OWNER•BUILD R DECLARATION Estimated Valuation hereby affirm that I am exempt from the Contractor's License Law for the following reason: (Sec. 7031.5,Business and Professions 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 PERMIT,-. AMOUNT the provisions of .the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, or that. he 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). ID 1, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal. do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const. Code: The Contractor's License Law does not apply to an owner of property, who builds or improves thereon and who does such work himself or through his own employees, Mech. . provided that such improvements. are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden Electrical of proving that he did not build or improve for the purpose of sale.) I.'l I, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing ' strucl 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.1. such projects with a contractors) licensed pursuant to the Contractor's License Law.) Grading 0 1 am exempt under Sec. B. & P.C. for this reason 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 CERTIF111OF EXEMPTION FROM REMARKS ' . WORKERS' GfOMPENSATION INSURANCE (This section need not be completedI t he permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance/,ffthp work for which this permit is issued, I shallnot employ any person in any manner o s to become subject to the Workers' Compensation Laws of California. Date Owner NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become ZONE: BY: subject to the Workers' Compeh tion provisions of the Labor Code, you must forthwith Minimum.Setback Distances: comply with such provisions or this permit shall be deemed revoked. Front Setbackfrom Center Line Rear Setback -rom Rear Prop.. Line CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line 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.) Side Setback tom Property Line Lender's Name Lender's Address This is a building permit when properly filled out, signed and validated, and is subject to FINAL DATE INSPECTOR 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. Issued by: Date Permit 1 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. Validated by: Signature of applicant —Date— Mailing ate Mailing Address -Validation: ' City, State, Zip ' BUILDING DIVISION"•' CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SO. FT. @ $ 2ND FL. SQ. FT. @ POR. SO. FT. @ GAR. SO. FT. @ CAR P. SQ. FT. WALL SO. FT. g SQ. FT. @ ESTIMATED CONSTRUCTION VALUATION $ 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 LlROUGH FLOOR DRAIN MECHANICAL FEES HEATING (ROUGH) WATER SOFTENER VENT SYSTEM FAN EVAP.000L HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER DUCT WORK GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM HEATING (FINAL) KITCHEN SINK ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET COMPRESSOR HP POLE, TEMIPERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SQ. FT. c BATH TUB BOND BEAM 6� a2 SQ. FT. p c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 11/a c SEWAGE DISPOSAL LUMBER GR. SQ.FT.GAR @ ?sc HOUSE SEWER FRAMING FINAL INSP. 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 STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE LlROUGH 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 APPJEQUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM 6� a2 WATER SYSTEM GRADING cu. yd. g plus x$ _$ LUMBER GR. FINAL INSP. FRAMING FINAL INSP. ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESANITIALS GARDEN WALL FINAL