9606-135 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed under provisions of
-Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
c%J W Professionals Code, and my License is in full force and effect.
=) co License # Lic. Class Exp. Date
O LO
W
Cr
Z r Date Signature of Contractor
Q I.
J U a) OWNER -BUILDER DECLARATION
WWW cn I hereby affirm under penalty of perjury that I am exempt from the Contractor's
co 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).
( ) 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:. for this reason
N ate &I. t Signature of Owner w
ON v v - . „i-•, ... ,
C
d< WORKER'S COMPENSATION DECLARATION
C:) 2 Cr I hereby affirm under penalty of perjury one of the following declarations:
Q () 1 have and will maintain a certificate of consent to self -insure for workers'
X W Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the -work for which'this
LO H permit is issued. My workers' compensation' insurance carrier & policy no. •are:
,It Z Carrier Policy No.
cbn
a
Q (This section need not be completed if the permit valuation is for $100.00 or less).
J ( ail 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
3 Code, I shall forthwith comply witHhose provisions. /j �.
Date: - Applicant �/ 4
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 propertyfor inspection purposes.
ySignature (Owner/Agent) - v •� �+ Date*.,•21• 91
..Y
BUILDING PERMIT PERMIT# CONTROL#
3572.DATE
fi/21r9,6 VALUATION $376-" LOT. TRACT
JOB ADDRESS 5X-6J54EISENHOWER IDR
APN 773-301-09
OWNER
CONTRACTOR / DESIGNER / ENGINEER
DANIEJ, G & S1•t,AR01;J P!; FNIICE
0SSWED'ilf ALDER
52654 91SENH0WV 003 .
1N IA0 CA 92201,
Ci31..1`€
USE OF PERMIT
14 WALL 4' ANU 3' GARD..N,N OL OCK 'WAIN., C0.M,. 80 C,f't'YY Sk'i",aC'S 10 V EACH.
4 FT. WALL it?:rK! Lf:
51,7. VNATA. W.00 LIQ
VS1'A4,JVrE1D C( -1,910F CONSTRUCRON
37"0
<;<7:►I�;{0`raJ€�rr4��tk�'t�L: R!)Q�f3(tQ•+�lFc„4'1(?�) �rs.ftp
S P - UI AL CUN 9 WAIC`E10N AN n PL,.AJN CHECK
'I
”J1 lJ.
'PTAL t"FRIMITYERS DOE NOW
$15.040
.i U N 1996
I '
By
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
t MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts i
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 Wail 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
NWG
074 -
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVA S
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:
4r
P.O. BOX 1504
Building2 �S 7&105 CALLE ESTADO
Address S l ' `^ May _ Q41NTA, CALIFORNIA 92253
Owner I C �
APPLICATION ONLY
TYPE CONST. OCC. GRP.
Mailing n `
Address G'y 2 -� l
A.P. Number
City
Zip
Tel.
r•' (:) ,.
Z z _ I
3 -/ o— '? I 1 13
Legal Description
Project Description
Contractor
Address
City
Zip
Tel..
State Lic.
City
& Classif.
Lic. #
Sq. Ft. No. No. Dw.
Size Stories Units
Arch., Engr.,
Designer
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address
Tel.
City
Zip
State
Lic. #
"
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am•I ci eep�?ed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the B sTness nd Professions Code, and my license is in full force and
effect. 1 2 — z. t �2 .
SIGNATURE .DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,8usiness 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
Estimated Valuation
,
PERMIT AMOUNT
Plan Chk. Dep.'" I'
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).
1-; 1, 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
Plan Chk. Bal.
Const.
Mech.
Electrical
or improvement 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 1 am exempt under Sec. - B. 8 P.C. for this reason
Grading
Driveway Enc. I
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
0 Copy is filed with the city. ❑ Certified copy is hereby furnished.
TOTAL
REMARKS
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 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: If, after making this Certificate of Exemption you should become
ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from 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 from Property Line
Lender's Name
FINAL DATE INSPECTOR
Issued by: Date Permit
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if 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 10 enter the above-.
mentioned property for inspection purposes.
Validated by:
Signature of applicant Date
Mailing Address
Validation:
City, State, Zip
BUILDING DIVISION
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. @ $
UNITS
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SO. FT.
HEATING (ROUGH)
STORAGE TANK
POR. SQ. FT. @
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. @
POWER OUTLET
ROOF DRAINS
FOUND. REINF.
DRAINAGE PIPING
CAR P. S0. FT. @
HEATING (FINAL)
OTHER APPJEQUIP.
WALL SO. FT. @
DRINKING FOUNTAIN
SO. FT. @
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
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, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. @ c
BATH TUB
SO. FT. p c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11A c
SEWAGE DISPOSAL
SO.FT.GAR @ 3/ac
HOUSE SEWER
LATHING
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 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 APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM ` 2
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
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL