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9605-062 (SFD)U) H N i) W O ::) Co C) LO W r- C Z r'^^ _ 0 W CO Fa - to Z N Oa as Z r�0 LL O J,Q co<U C5 o Il rn H It Z co Z) �0 Q J LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjurythat 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 6'13 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). . 1 () I am exempt. der Section B&P.Cf c.tiis reason ... Date R✓ ✓ Signature of Owner�G�e� 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, fort he 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 AV!%}!<fia`f k0 ifvliUl i` Policy No. 380.4 �7S/i I) -44 (This section need not be completed if the permit valuation is for $100.00 o'r 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 he Labor Code, hwfth comply with those provisions Date: Applicant`= Warning: Failure to secure Workers' Compensation coverage is'unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for,in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void.if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information. is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of thieCit to enter upon the above-mentioned property for inspec ion pu ' Ses�' Signature (Owner/Agent), y Date BUILDING PERMIT PERMIT// CONTROLk ✓�` 3499 DATE fif13%1b VALUATION '$I 72,1-21 ,4t LOT, - TR 4C ,1 t) JOB SITE_ DDREss 71)- 165 vox HIli�, APN �Piy-5S-,fi-1S OWNER CONTRACTOR /DESIGNER/ ENGINEER 1 etc t. tw,t , QRu.1,1-FA1`l'D COf,'A uit filT ttleJiJN IvdN tll\i KivYh 6443 kf i��1�Ct+N hili "VVS PD LA i,A?f NTA I -A C. IIIN'I A (.'A. 92253 �y-iW.9<.f fl�ld�t,s(e�t-lRaft�. `'.141,4: :iti�r► USE OF PERMIT NV1)-:1t1 Rh4f'i f x 113 NOT !t*_i.fiOY ti1S.WY' WiVJ. f?s.x"aL, PlA�.l�,fITREFLECTS A.4".RF-f)JT Of 9tti';ii �li't'i°'i /A&d f'r•:'1P! f�Iiltt,ir' t�fi,rlr:`l;"i 4�1;f2 ��'l1d:f:}�(ttf+.1J'1' t1/t'j'if („e;1�•f'}�4tFfdl'F'�r” 1�f;�1f°f.t�lyi�(1:'?J'i,'. 'U36.00 sill t;?s�i t�('il.<I("F1T�Piai '3' 6tlfi,tl�t St., K;T I Vt.A:€;t� D `>� T �3. CONSTRUCTION $72..k A.5(i PERMtT FEE SUMMARY f flTJ'i i'ii�t'f;�.tnN f Fl; 101-000-4!1;-00 S}S n(► 11Ard C; WC 1111-000 4.19�318 $7�4, 2 VEE I %f 0t 41'1 4250.80 t�tEE`iIANfCa1L 'r^i't 10:f' -OW 21-600 S".50 f l,FC'�'+Ri�,A"f.`l!'a!� lt)?=C1i3f), il•�ff'If) vi"O.."wING � 101•-000.40.000, 517000 C-7 STC,I 01. MU`117(J.IN F.ffi - IILESlD GRADINO.FEf: 101 _0tkl-423-ow sMf3. o INFf? A!;`i'.0rCWRC. i SAIWMITAL c;:C?Ft'ti`i'�t�IXMI DN AND PLAN CHECK i FSS kE—IJAID FEES 4250.00 TOTAL PERMIT FFE.' Olti»+E NO �5�GS9.tii RECEIPT DATE BY DATE FIN LED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs 5 Underground Ducts Forms & Footings S' Ducts Slab Grade Return Air. Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor Insulation - 2 Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wail Insulation Condensate Lines Party Wail 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 Plbg. Test Final I I Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines O - Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster S r Lateral Pool Cover JZ29 Connection U' Encapsulation Gas Piping Gas Test 7 D - Appliances Final Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fodures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final 16 7 —ZY A10 Utility Notice (Perm) COMMENTS: Building —7� / Address l P.O. BOX 1504 APPLICATION ONLY 78-105 CALLE ESTADO Z 1( U .,IfA QUINTA, CALIFORNIA 92253 od Owner ��i "-tis s >2r Mailing Address City.% Zlp��� J 3 Tel. Contractor. — Address Zip State Lic.I City & Classif. Lic. # Arch., Engr., Designer el. Cily If IZipq,27/41 (State I h-- Lic. # LICENSED CONTRACTOR'S 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. 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,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 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 subjects the applicant to a civil penalty of not more than five hundred dollars ($500). 11 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, Buisness and Professions 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, provided that such improvements are not intended or offered for sale. If, however, the building 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.) 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 such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) 11 1 am exempt under Sec. B. & P.C. for this reason Date Owner 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 C7 Copy is filed with the city. 0 Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (8100) valuation 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. Date Owner NOTICE TO APPLICANT., It, after 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 sof this city to enter the above- mentioned bovementioned property for inspection purposes. Signature of applicant Date Mailing Address City, State, Zip BUILDING DIVISION BUILDING: TYPE CONST. 6r-6. OCC. GRP. A.P. Number Legal Description Project Description / _�O G 5 p — () `Q,�� Sq. Ft. Size No. No. Dw. Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS 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 DA Issued by Validated Validatior CONSTRUCTION ESTIMATE NO, ELECTRICAL FEES NO. PLUMBING FEES IST FL. _._ SO. FT. @ $ UNITS SLAB GRADE ROUGH PLUMB, BONDING YARD SPKLR SYSTEM 2ND FL. SQ. FT. @ FORMS SEWER OR SEPTIC TANK POR. SO. FT. @ MOBILEHOME SVC. BAR SINK GAR. SO. FT. POWER OLJTL I ROOF DRAINS HEATING (FINAL) OTHER APP./EQUIP. DRAINAGE PIPING CAR P. I SO. FT. TEMP. POLE WALL SO. FT. GROUT DRINKING FOUNTAIN SO. FT. a FINAL INSP. URINAL ESTIMATED CONSTRUCTION VALUATION $ WATER SYSTEM WATER PIPING NOTE: Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES FINAL INSP, WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM 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. SO. FT. B c BATH TUB GAR. FIREWALL SQ. FT. p c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 7+/. c SEWAGE DISPOSAL SO.FT.GAR R' 3/ac HOUSE SEWER INSULATIONISOUND GAS PIPING PERMIT FEE FINISH GRADING 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 R AIR COND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C. UNIT COLL, AREA SLAB GRADE ROUGH 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 APP./EQUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING cu. yd. $ 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. OCG. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL a