0104-220 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby 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
733'15x 3 03/3112(
Date ' Signature of Contractor d _
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. z,
(r"%) 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.
CAL Y1+I%AFKAITY H3062174A
(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: 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 this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0104.220 TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PO.h WWx P09'tr>lff17AL A,5MUW1014
DEL MAR PA.C."•MM OMP—RAL COM :R A,C. )0 .
PO BOX dWO
462 s`1"MM3A 02
LAQ111 r._rA. CA 92253
SOLA.AIA, MACM M 92075
(855)732a1500 CFL' ft. 5823
LOCAL OFMCE4 INFORMATION
USE OF PERMIT
bMSCELLANEOUS
75.160 ST. CHARIX-S PL
-3'A n X38 -374 & 54-362 OA.t(. TREE e BUILL2.lNU IX ` YPE
101 OLMOTARY STRUCTURAL Ia ODIF.ICA i 1043 I /
VALUATION 20,000,00 1Z
'MMIM) 6:03' Ole C`t3NMG' ION
PPIUMV1'.7, 9Uib+ 1. XY
C.ONSTRUCT100 FES: 101-000-418--000 $_207.00
S'TROW41 MO'6'ION FEF-- XF31O '101-000-241-000 $Z.�
D �A sin -XOY AL C( ?=170),T AND PLA14 L'`•iMCK
LAS PAID M.3
912C2f�.Eiff
S0.00
APA 2 0 2001 L.FERMT F103:5 DU'X .NnW
11,209,00
CITY OF LA QUINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
S,J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
[INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts i
Forms & Footings
Ducts [
Slab Grade
Return Air [
Steel
Combustion Air 1
Roof Deck
O.K. to Wrap
�� /(,�J �,Q�_
Exhaust Fans {
F.A.U. [
Framing
ir {
Insulation
Vents {
Fireplace P.L.
Grills {
Fireplace T.O.
Fans & Controls [
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath/Z�j�p�
L,•/�L
[
Drywall - Int. Lath
LOW
_
Final
` BLOCKWALL APPROVAf S
Final [
POOLS - SPAS
Steel j
Set Backs
Electric Bond [
Footings
Main Drain {
Bond Beam
Approval to Cover i
Equipment Location {
Underground Electric
Underground Plbg. Test {
Final
Gas Piping t
PLUMBING APPROVALS
Gas Test i
Electric Final j
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 t
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)
Page of
Y DAV&STEAVENS
Inspec.. ont: Services
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PROJECT<, b �� �- ��s (. A: �. PROJECT #
;:
ADDRESS
E3-� Lsr"� CLIENT
DATE SwJ �. AZ c5o
BLDG. PERMIT # ARCHITECT
ENGINEER .,
�j ,,..,,�,.�, it, CONTRACTORj��
INSPECTION TYPE
i
INSPECTION REPORT i
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CERTIFICATION OF COMPLIANCE To the best 'of our Knowledge, all of the,reported-work; uriless otherwise.noted,
^substantially complies with approved plans, specifications and applicable sections of the.building codes: This report covers
.,,ihe locations of the work inspected only and do es.not.constftuteengirieenng opirnon or..project control.
j 4CERT. NO. OSIS ��34!2 •: SU I INSPECTOR;NAME J'C 0--,
.DATEL. r�i �rJn I INSPECTORSIGNATURL.,✓
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DAVE $TEAVEN.S I
Inspection :Services -
PROJECT (:; vJ �.s—� �� Asp (A PROJECT '#' c.7, v-0
ADDRESS A',st_ t Sit CLIENT' >�G 5' Ho A '
DATE _l3 .�'�;c, j C
BLDG. PERMIT # ARCHITECT Goth A .c c ru rzC, j
ENGINEERl �oJ f i S- � J o I E ► hi' (. CONTRACTOR
E L' i>� rq +e PAC i -/C-
.,...INSPECTION
rrC-INSPECTION TYPE ..r!!: PDXY
a,
INSPECTION. REPORT
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CERTIFICATION OF COMPLIANCE To tFie best ,of our knowledge, all of the reported work,:unless:otherwise noted;
Dhe
bstantially complies with approved plans; specifications and applicable sections°of;the building•codes.This report covers
locations of the work ins pected'onlysnd does`not constitute engineering:opinion or• project -control..
CERT. NO. INSPECTOR NAME ,sti
/ r(Prim Cleary):
DATE NSPECTOR SIGNATU