1579NOTE:
With proper validation
• this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement Permit — Class III
,DATE: October 19, 1992 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 78-9SO MM t 11 - stM AA;+� R*Tarr Ar
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION n"trical conduit Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION 20 bate I
SEE ATTICSBD CMMM.
DIMENSION OF INSTALLATION OR REMOVAL e0 SEE 6TTACM MUM '
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 10/20/92 ti
APPROXIMATE TIME OF COMPLETION 10/24/92
ESTIMATED CONSTRUCTION COST $ 3,000
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnify, defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities. or loss resulting from claims or court action and arising out of any accident, loss,or damage to persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the resu o thisrk.
1
Signature of Applicant or Agent
Day Construction 18448 Ward St. Fountain Valley* CA (714)963=0971
Name of Applicant (please print) Business Address Telephone No.
M i F Oadartround
Name of Contractor and Job Foreman Business Address Telephone No.
610643 2135
Contractor's License No. City Business License No.
Itronk B. Hall (714)611-8353 CLS007774
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction. costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by Date
1J5i9
PERMIT VALIDATION
PERMIT NO. 1579
DATE APPROVED 10119/92
EXPIRATION DATE 10/30/92
DATE ISSUED 10/19/92
By ,xKA
dministrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
The following General and Special Provisions are attached to and made a part.of Permit No. 7q
GENERAL PROVISIONS
The following shall always apply:
ENCROACHMENT ON PRIVATE PROPERTY: This permit authorizes work to be accomplished within City of La Quinta right of way
ONLY. Whenever construction extends within private property, it shall be the responsibility of the permittee (or his contractors) to
secure permission from abutting property owners. Such authorization must be secured by the permittee prior to starting work.
TRACKLAYING CONSTRUCTION EQUIPMENT: Cleated tracklaying construction equipment shall not be permitted to operate on any
paved surface unless fitted with smooth -faced street pads. All mechanical outriggers shall be fitted with rubber street shoes to protect
the paving during excavations. Rubber -tired equipment only shall be used in backfill operations in paved areas. If the existing
pavement is scarred, spalled, or broken during the term of this contract, or if the pavement is marred, City of La Quinta shall request
that these portions of road be resurfaced over their entire width. Resurfacing shall consist of one coat of two inches (2") of A.C.
surfacing plus appropriate seal coat as specified above.
PROTECTION OF TRAFFIC: All excavations and work areas shall be properly lighted and barricaded as deemed necessary by the City
Engineer or La Quinta City Public Works Inspectors. Suitable detours and detour signs shall be placed and maintained for the duration
of the project. The City shall be notified 24 Hrs. in advance of any traffic detours or delineations.
CARE OF DRAINAGE STRUCTURES: Any drainage structure including corrugated metal pipe, concrete pipe, steel culvert and
concrete structures encountered during excavation which necessitate removal shall be replaced in kind. In the event -it becomes
necessary to remove or cut existing drainage structures, City of La Quinta shall be notified prior to commencement of this work.
Drainage structures and open drains shall be kept free of debris at all times for proper drainage.
RIGHT OF WAY CLEANUP: Any surplus material resulting from excavation and backfill operations shall be removed from the right of
way. All paved surfaces shall be broomed clean of earth and otherobjectionable materials immediately after backfill and compaction.
Existing gutter line and drainage ditches shall be replaced to their, original standard or better. All excess material shall be removed
prior to paving. Water tanker shall be used, as required, to sprinkle the job site to keep down dust conditions and shall be used
immediately after backfill.
DE -WATER OPERATIONS: If de -watering operations are required and pumps are forcing water on City of La Quinta roads, it shall be
the responsibility of the permittee (contractor) to control this water and to provide off-street barricades when necessary.
CLOSING STREETS: No street shall be closed. A minimum of one lane of traffic shall be maintained at all times to provide limited
access for the adjoining property owners and emergency vehicles. In the event it isfelt bythe permittee that he must close a street for
any length of time, permittee shall contact this office to obtain the necessary permission.
SPECIAL PROVISIONS
The follwing shall apply ONLY when indicated:
R1 NOTIFICATION: Permittee shall notify the City at 564-2246 at leas l,48 hours in advance of starting construction.
R2 CASH DEPOSITS OR BONDS: A cash bond or an approved surety bond in an amount of not less than $
shall be furnished in the name of City of La Quinta to cover all work involved in the restoration of the various La Quinta
roads and survey monuments. This bond shall be continuous until cancelled by the City Engineer. This bond must be
posted prior to commencement of any work on this project .
R3 UTILITY CLEARANCE: (Substructures) Priorto making anyexcavationwithin the City ofLaQuinta right ofwayauthorized
by permit, the permittee shall contact all concerned utility companies relative to the location of existing substructures.
Damage to existing substructures resulting from operations conducted under this permit shall be the sole responsibility
of the permittee.
CRUTILITY CLEARANCE: (Surface structures) No work shall be done under this permit until all utilities are clear of the
proposed work site. The permittee shall notify all concerned utility companies of the proposed work.
R5 PAVEMENT WIDENING: Area between the proposed concrete gutter line and the existing road pavement shall be
surfaced with inches of A.C. paving placed on inchesof class . aggregate subbase course
having an"R"valueof not lessthan and in conformance with City of La Quinta Road Improvement Standards
and Specifications, Ordinance #461.
R6 PARKWAY GRADING: Area between the property line and top of the proposed concrete curb shall be graded to a slope of
1/4 inch to one foot (1').
R7 GRADES & STAKES: City of La Quinta shall establish grades and stakes for the proposed concrete curb and gutter
construction.
RB GRADE CHECKING: City of La Quinta shall checkgrades upon receipt of plan and pFofile and/or grades asestablished by
a licensed engineer.
R9 CURB REMOVAL FOR DRIVEWAYS: A portion of the existing concrete curb and/or curb and gutter ( feet)shall be
removed. Curb and/or curb and gutter shall be saw cut prior to removal. Depressed curb, matching concrete gutter and
concrete driveway approach shall be constructed in conformance with City of La Quinta Standard #207.
R10 DRIVEWAYS, A.C.: Driveways. shall be constructed as not to alter existing drainage pattern. Surfacing between the
property line and the existing road paving shall be 2-1 /2 inches of A.C. paving placed on (-") of class
aggregate base. Driveway construction shall conform to attached drawing.
R11 CULVERTS: A inch diameter (-)culvert shall be installed with the invert approximately 1-1 /2
inches below and in line with the existing flow line. Culvert installation shall conform to the attached drawing.
R12 SIGHT CLEARANCE: Sight clearance of 600 feet in either direction shall be assured and maintained.
R13 SOIL STERILIZER: The area to be surfaced shall be treated with soil sterilizer. Rate of application shall comply with the
manufacturer's specifications.
R14 COORDINATE WORK: The proposed work shall be subordinated to any operation which the State of California or
City of La Quinta may conduct in this area during the period of this permit. Work shall be coordinated with the State or
City of La Quinta forces to preclude delay or interference with State or City of La Quinta projects.
R15 URVEY MONUMENTS: Prior to excavation or beginning of construction, all survey monuments which exist on the
centerline of all streets or property lines when involved shall be completely tied out so they maybe readily and correctly
be replaced by a licensed civil engineer or surveyor at the expense of the permittee. A complete set of notes showing the
ties to these monuments shall be furnished to the City Engineer prior to the removal of any monuments. This office shall
be notified upon completion of replacement of all survey monuments for proper project clearance.
RD -31
R16 SURVEY MONUMENTS: Prior to excavation or beginning of construction, all survey monuments shall be tied out by City
of La Quinta and suitable payment or guarantee of payment shall be made as reimbursement for all work involved.
R17 PAVEMENT CUTTING: Pavement will be mechanically cut to a straight edge prior to excavation. Method of pavement
cutting shall be approved through the office of the City Engineer. (Under no circumstances shall excavating equipment
be used to excavate prior to cutting of pavement). Excavation material shall be placed in such a position as to best
facilitate the general flow of traffic. Prior to final paving operations, any damage to pavement straight edge shall be
corrected.
R18 PAVEMENT CUTTING: Pavement shall be saw cut prior to removal. Prior to final paving operations, any damage to
pavement straight edge shall be corrected.
119 LIMIT OF EXCAVATIONS: Excavations shall be limited to 1,000 lineal feet of open trench before backfill operations must
begin. All excavations shall be properly barricaded with lights overnight, on weekends and holidays forthe protection of
the traveling public. The Public Works inspector shall determine the suitability of excavation barricading in each case. No
excavation shall remain open for a period exceeding five (5) days. No excavation shall be made unless the construction
material is actually on the work site.
R20 BACKFILL MATERIAL: Backfill shall be free of brush, roots or other organic substance detrimental to its use for purposes
of producing an adequately consolidated backfill. Any material which the City of La Quinta deems unsuitable (spongyor
saturated material) which is encountered during excavation shall not be used for backfill, but shall be supplemented or
replaced by an approved sand or gravel.
R21 BACKFILL SAND: Backfill shall be approved transit-mix sand or equivalent and shall be placed in lifts of notgreaterthan
three feet (31 and vibrated using vibrotamper or equivalent equipment. Alternate methods maybe substituted, but in any
case a relative compaction of 95 percent shall be attained within the structural section of the roadway.
ER22 BACKFILL PLACEMENT: Backfill shall be applied in layers of not more than 50 percent of the total depth of the trench
before flooding or a maximum of five-foot (5') liftswhere trenches are of excessive depths. Care isto beexercised thatthe
backfill material is not subjected to extreme swell by flooding operations. Backfill material shall be placed so that the
resulting compaction shall be not less than 90 percent or equivalent tothe surrounding ground, whichever isthe greater
compaction. Where ponding or flooding is used for a maximum settlement, adequate dikes will be constructed to retain
the water. Where jetting is used, the jets shall be of sufficient length to reach the bottom of each layer and the water
supply shall be continuous.
R23 COMPACTION TESTS: If so required bythe inspector, compaction tests shall be made at intervalsof not more than 1,000
feet and a minimum of one (1) test on each road. One (1) copy of each test shall be forwarded to the City Engineer for
approval and filed prior to making permanent repairs. Compaction tests shall be made as outlined in Section 6.3.01 of the
Standard Specifications, Division of Highways, State of California, dated January 1973.
R24 COMPACTION TESTS: If so required by the inspector, compaction tests shall be made for each crossing or service line.
One (1) copy of each test shall be forwarded to the City Engineer for approval and filed prior to making permanent repairs.
Compaction tests shall be made as outlined in Section 6.3.01 of the Standard Specifications, Division of Highways, State
of California, dated January 1973.
R25 TEMPORARY PAVEMENT REPAIRS: After completion of backfill and compaction operations, a temporary patch
consisting of 2 inches of SC -800 shall be placed on a prepared subgrade. The SC -800 temporary paving shall be placed
after a maximum of 3,000 lineal feet of trench has been excavated and backfill operations completed, but in no case shall
the placement of the temporary pavement exceed a five (5) day limit.
R26 PERMANENT PAVEMENT REPAIR: After backfill and compaction operations have been completed, a temporary patch
consisting of two inches (2") of SC -800 shall be placed immediately. A permanent patch of inches A.C.
surfacing placed ona inch class baseshallbeplacednolaterthan days after completion of
temporary road repair.
R27 PAVEMENT REPAIR: F.A.S.: Uponcompletibn ofbackfill andcompaction, a temporary patch consisting of two inches (2")
of cold mix paving (SC -800) shall be placed immediately. A permanent patch of three inches (3") of A.C. surfacing shall
be placed on six inches (6") concrete base as directed, but not later than fifteen (15) days after completion of temporary
paving. Concrete base shall be of five -sack mix and shall conform to the City of La Quinta Road Improvement Standards
and Specifications, Ordinance #461.
R28 FOG SEAL: A fog seal coat consisting of an application of asphaltic emulsion shall be applied over all patch areas as
determined by the City Engineer,.
R29 SEAL ARMOR COAT: A seal coat consisting of an application binder and screenings shall be applied on all patch areas
where such seal coats existed prior to issuanceof this permit. Seal or armor coats shall be applied as specified in Section
37, Standard Specifications, State of California, Division of Highways, dated January 1973. Work of pavement repair to
be accomplished by a licensed contractor engaged in the business of pavement repair.
R3 STREET RESTRIPING: Where street striping is still visible on streets to be excavated, such striping shall be replaced upon
completion of permanent repairs.
R31 TREE RELOCATION OR REMOVAL: Tree relocation within the City of La Quinta road right of way shall be accomplished
by a licensed, bonded and insured tree service, and handled safelywithout interference or hazardtothe traveling public.
It shall be the responsibility of the permittee to maintain the tree in a vigorous growing condition at its new location.
Trees to be removed shall be removed in sections which can be handled safelywithout interference or hazard to highway
traffic. The entire width of the tree stump shall be removed and disposed of so that no debris remains in view of the
highway. The stump hole shall be backfilled and thoroughly compacted as specified in thefollowing paragraph. Where it
becomes necessary to restrict traffic, the work shall be restricted to a maximum of 500 feet at any one time. Adequate
signs, flagmen and/or barricades shall be provided to protect the traveling public at all times.
Large holes resulting from tree removal shall be backfilled and compacted to not less than 90 percent or equivalent to the
surrounding ground, whichever is the greater compaction as determined by the impact or field method. Compaction
tests shall comply with Section 6.3.01 of the Standard Specifications, Division of Highways, State of California, dated
January 1973.
R32 TREE TRIMMING:
a. Only the necessary trimming shall be accomplished to provide clearance of the facility for one calendar year.
All broken or weak sections within the trimming shall be removed.
b. Where it becomes necessary to restrict traffic, the work shall be restricted toa maximum of 500 feet at anyone time.
Adequate signs, flagmen, and/or barricades shall be provided to protect the traveling public at all times.
c. If tree trunks are partially outside of. the City of La Quinta road right of way, permittee shall make his own
arrangements with adjoining property owners for consent to the trimming in addition to the authorization provided
by this permit.
d. All tree trimming on EVERGREEN TREES, PALM TREES, and other ORNAMENTAL TREES shall be accomplished to
the satisfaction of the City Public Works Inspector.
e. Abutting property owners shall be contacted, in all instances, prior to trimming or topping trees.
f. Pruning shall, in all instances, be at the shoulder of the crotch to insure even, fast healing in all cuts of two inches
(2") and above in size. Sealant shall be applied to all cut sections as directed by the City Public Works Inspector.
ADDITION ----ENCROACHMENT PERMIT NO. 1519 ----CONDITIONS
R33 Survey monuments shall be protected in place or re-established
pursuant to ,City standards and the State of California Land
Surveyor's Act.
R34 Work shall be coordinated with the City of La Quintals forces
to preclude delay or .interference with the City of La Quintals
projects.
R35 Contractor shall comply with the local noise ordinance.
Construction operations and maintenance of equipment within
one half mile of human occupancy shall be performed only
during the time periods as follows:
October 1st to April 30: Monday -Friday 7:00a.m. - 5:30p.m.
Saturday 8:OOa.m. - 5:OOp.m.
May 1st to September 30: Monday -Friday 6:OOa.m., - 7:00p.m.
Saturday 8:OOa.m. - 5:OOp.m.
Work shall be prohibited anytime, on Sunday and Federal
holiday:
R36 Traffic control shall. be as per Cal Trans Traffic Manual.
Field adjustments in detouring shall be accomplished as
directed in order to adjust to actual field conditions. It
shall .be the contractor's responsibility to adequately
barricade and detour this site. A Traffic control plan shall
be submitted to the City Engineer for approval prior to any
work in.the travel way.
R37 All excavation at or near the travel way shall be backfilled
at the end of the work. day, for the protection of the
traveling public.
R38 Street closures shall not be allowed at any time.
R39 Ingress and egress for local properties shall be maintained
at all times.
R40 Prior to work starting, Underground Service Alert shall be
contacted at 1-800-422-4133 and an "inquiry number" shall be
provided to the City Public Works Inspector.
R41 No pavement cutting is permitted in the traveled section of
the roadway except to pothole conflicting utilities.
Additional Conditions - Encroachment Permit No. 1579
Page 2
R42 All backfill subgrade soil shall be compacted to'nothing
less than 90% relative dry density, all backfill soil within
the top 2.' of finish pavement surface shall be compacted to
nothing less than 95% relative dry, density, all base
material shall be compacted .to nothing less than 95%
relative dry density.
R43 Replacement pavement section shall be i" greater than
existing.
R43 In advance of excavation, Contractor/permittee shall submit to
the city for acceptance a detailed plan, in accordance with
Labor Code Section 6705, showing. the design or shoring,
bracing, sloping, or other provisions to be made for worker
protection from the hazard of, caving ground during the
excavation of trench or trenches five feet or more in depth.
If such plan varies from the shoring system standards, the
plan shall be prepared by a registered civil or structural
engineer. As part of the plan, .a note shall be included
stating that the registered civil or structural engineer
certifies that the plan complies with the Cal OSHA'
Construction Safety Orders or' that. the. plan is not less
effective than the shoring, bracing, sloping, or other
provisions of the Construction Safety Orders.
R44 Contractor/permittee shall be responsible for the control of
any fugitive dust that is created by his construction efforts
or a result there of.
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Call:. TOLL FREE
1-800
422- . 4133
TWO WORKING DAYS BEFORE YOU DIG
NOTE:
With proper validation
this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other like public works improvements in' connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
�D Subdivision Improvement. Permit —Class I I I
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 78 -15-0 ii/r.� A 9" / // / a A D-14 --
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION --
E—c 7-71? /.c *+-e– e mnJ Dv e'r-
DESCRIPTION OF CONSTRUCTION 2:0"
DIMENSION OF INSTALLATION OR REMOVAL 0 r
SIZE OF EXCAVATION, IF NEEDED
Sketch (attach construction plans if appropriate)
ep ND 17 i onJS
APPROXIMATE TIME WHEN WORK WILL BEGIN /yZO -AZ
APPROXIMATE TIME OF COMPLETION w - °/ 2—
ESTIMATED
ESTIMATED CONSTRUCTION COST $ 3000
(Including removal of all obstruction, materials, and debris, backfilling, com.
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnify; -defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happening or occurring.as a proximate result of any work undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result of this work.
Signature of Applicant or.Agent
Z>iL/ /L)57-- /6'yyt~' wA-ieD 57— ry-1A)mlc) iIALl-6`/ 7/Y 963-o97/
Name of Applicant (please pant) Business Address Telephone No.
f Y' r./NDf4690wNx
Name of Contractor and Job Foreman Business Address Telephone No.
6/66 y3
Contractor's License No. City Business License No.
�re,�cJ ,s1 � . f%9 « C o • % %/ y) G l/ 8.�s � c �.s .,�, � � � �
Applicants Insurance Company Policy Number
FEES- Subdivision Improvement Permit — Class I I I
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ I�
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
1?�F�
PERMIT VALIDATION
PERMIT NO. sr-
DATE
DATE APPROVED �� /� 9Z-
EXPIRATION
ZEXPIRATION DATE 10 ^ 30 " qZ
DATE ISSUED /0 �� / f 2-
By
Administrative Authority
TELEPHONE: (619) 564-2246
'�
` 'y � � ;
�,t a ,,
• .`
t
`, � , �
a'
Of
P.O. BOX 1504 N o . .110 4.6
Building 54-66S Ave.Rub is M105 CALLE ESTADO
Address LA OUINTA, CALIFORNIA 92253
Dog
di Jones & Paul McCain
Address P. 0. Box 1773
City Zip Tel.
Indio 92202 .399-5528 '
Contractor
Herbert G. Adams
Address
57020 Monroe
City f'P9
Tel.'Thermal 2279 399-5528
State Lic.
" Claw"- B 211280
ArctL, Engr.,
Designer
ILDING: TYPE CONST. OCC. GRP.
'..Number
New U
Address Tel.
C" iP Staley` ..
Lfc: #.:
'410DgED OOWfilI11lC=11* DECW1A71pN
I afM., tint 1 am Uosrheed under Provision of ChWW 9 (oommerictria umb:1 8mon 1 t
al DfMsion3 or the ewlness Protesalons Cade, end my IlCaw M in ho face end
QATC
OWNER -BUILDER DECLARATION —�-
reaaort�alec. 77031.affirm 6,0,Bunhess and prI am exempt oluab w � s its ones Law for h sgubfolloe :6 '
Any oft « poorly .etch *snoffi : e
P0101011 d oaraoucr, star, bProv'e, dernafsh, or repair � strhrcbre, Odor to ills fsuanw •Ito.
r Mies tae spicaht for such Pemr to /e a statenmit that -he i.�esrts 1 P,,*uwY Vp
Me Provibs of tM Contractors Lkanse Low, ChWfor 9-(0Wm"no&0.60 aeotion 7000).&
of the Buefars and ProhsslonsCodo. or hast. tie fs exempt 1r/errrrsw, soil !ts beak
ofwped ass Wdm. Any Mofwbn of Section 7091.6 try 'arty r1 11 1 for a_ petal!
APpfosdhte a Cf/ PadfY of not more Ihan rive hundred dollars 0600). ;
Of the Property, or my employesa.wlth wages as their sole oompsna w l,'
k end the structure Is not Intended or offered for safe. (Sea -7#", Blithe" aced
Plorsokns Code: elle Oonbac(or's License Law does not da* to on owmr.of property ala .
arils er /rpro..s &moon and who doss such rwk 'hhawf or Vvorph Ak �oi n -0* lyose. ,t
Provided OW ouch hpovwrmts are not Intended or Offered for, 8010. F, hOakw: she' l
a feprovssrermA •said -V*t one year of comOkdon, the oww.drdr..ilJr01s=tlN Ori p.^ i
or prong Mit he did mot lard or kwom for the pwpose Of sok.) . Fi
O L, as oarrverd the properly, am exclusively contracting with licensed eontriglars to oor►:
struct the project (Sec. 7011, Bushels and Professions COO: The Contractors LAW=* Law-::
dos net spy lo an ower of properly -who bullsthereon, or k proves eon, sail -dro conoacts far" j
such P+gFcrs rot • Oontractorrs) fcenood pwauent to the Contraotws Lbonse Lowj.. •'
Q I aw exempt under Sec. a, b P.C.-for this reason
Oris Owner
4.
WORKERS' COMPENSATION DECLARATION
W.=Cu.by
=thave
aaniiaconsent to sefrine « e o.t
Insurance, aoetewDYCode.).
ticw or
thereof. fSec. A600.'laeor Code.) •
T- ComDenY
C-:�t.Bled with the lty. O Certified copy Is hereby tumlatsd.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(TMs sock m need not be competed O Ole perme is for one hundred, (tt 100) vehsOlon
or kss.)
1 cantly that in the performance of the work for which this permtt is Issued, i shad not
employ any person in arty manner so as to become subject to the Workers' Compensation
Laws of California.
Data Ow
N0710E 70 APPLICAM7:e
Y, after mekkp Ors 'Cerfdkate of Exemption you shot/d became
arhgiecf 10 es t/t>.Aws' COmpensadon provfabm Of the Labor Code, you must 1afAwim
campy ooh such ProvfdOm Or dms pemmi shay 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. 9097, Chi Code.)
Landers flame .
Lacers Address
kis a bullding papLyi..whenproperly filled out, signed and validated and Issubject to
Nwork'therourrmddeel/Is suspended for 180 days.
that I have read this application and state that the above Information is correct
I to comply with all city and county ordinances and state laws slating to building
arid Property fhwebyor auttlon purposes. authorize representatives of this city to enter the -ebars•..
Signature of applicant
MaHbV Address
city. State, Zip
.Add O '-..'Alter D-Aepair 0
Demolition 0
eria it.- oez ;•xiot::i-nclede -.block walls
MIT
Plan Chk.`DT 0.
-Plan Chk. 8a1:
,Jbof st.
Il tech.
-,)Plumbing. -
tarat9Ing .
A.
71
TOTAL
ani YrS Y�a' V D,:�'•• :'.y'�.C:'
r
299,11.1181
REMARKS
ZONE
BY:
Minimum Setback Distances:
Front Setback from Center Line
'Rear Setback from Rear Prop. 41ne
Side Street Setback from Center Line
Side Setback from Propertyiine
FINAL DATE
-INSPECTOR
tssued.by:
Date "Permit
Validated by:
Validation: