0302-106 (PAT)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
Date Signature of Contractor .Cp'>
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.
( ) 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 * 2 (,,H IN& CO, Policy No. VJ0:19385240#
(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 wit�h1hos provisions.
Date: Applicant-��1`�' . ,k
Warning: Failure to secure Workers' CoFnpensation 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.
Date
Signature (Owner/Agent)
i
BUILDING PERMIT PERMIT#
DATE ;� / /% VALUATION LO f' TRACT
7 $15.478M
JOB SITE APN
ADDRESS 41.9-401. AV.%:N.1<DA O's.MeGON 7 1 1 ., _
OWNER CONTRACTOR/DESIGNER/EN INEER
102.:.0EVEL(YPMT_T :(' CORPORKIM.4 I: i I' �El+EI.0111VENT C'Ok2.POI.dI:'T"..!'IN
5:5-9:10 PGA BIND 5�•, 201--GA:F31..YP
1.,A QTfr1, JVA CA 92233 IA QiIWTA Cry 92253
( 60)564.7166 CBIX 46+116
USE OF PERMIT
t 1�0 a^�' Ct�tr�tlPr_� Sfl.R.ra� �'�'�aiJC'�lir'Z2!",fp'f�i±"CPRC:U'NF� P�fF A."r'Ff#.t:�i'T+�i�
PL&NS ANLL STRUCTURAL CAIX-1.
060,00 SF
M1.4g4 :l ) COSI' OF CONSTRUCTION
N
PERMIT YFE SUMMARY .1 1
PIAN CHEM Vee 101.000-4.39.3I8 $111.15
CONSTRUCT T 1014 FER 101-ttW-11 I8-000 $171.03
STRONG V.0710W i • COMM 00.000 -?.41-000 13,24
.1 5,420M
SUWTOT'AL CO2d tIMMON PHU' IaI.AU-Ci MCK $1185.39
ISS 1RT9-PAM:Iv'1±;'u 4s0.00
I'LYFAL PMM13YEES DUE NOW
RECEIPT DATE/, BY D FIyALD/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final z /i, 3
BLOCKWALL APPROVALS
Final
POOLS -SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
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. Pourer Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Din #
Cgy Of --La:Q&1J`t
B dildihi &r. &iiery D' on
P.O. Box 1504;78-4951ttallOt-aimpico
r.1
Permit #
-1
La Quints, CA 192253 - .(760).777-76'12
c�3o?fi�thl
•
Building Yda6d.:Tracking Sheet
.
Project Address: CL
tU.
%%mcrs.;Name:*
A. P. Number: j
ss:
Legal Description:
City. ST. Zip:
Contractor:
elcphonc:
Address: L
t i
Project-Descriptidit:)
Citv. ST. Zip:
'f
Telephone: (2/
... .. .. ...
. .. . ...... . .
State Lic. # Citv Lic.
Arch.. trier.. Designer:
Address:
7—
CityAT, Zip:
Telephone:
n tructi'
..on -T% -pc:' Occupancy:
State Lic. 0:
P�r0ject'n. pe I cirde one): Ne%% Add, -n Alter Repair Demo
0 Name of Contact Person:A/&—V
Sq. 17t.-: &.Stories: `6.Units:
Telephone ;4 of Contact Person: ,_!�;C? 12�
EstimatedValu . c of Prq� cc z
APPLICANT: DO NOT. -WRITE BELOW THIS. LINE
Submittal
'Rec'd,
TPUCK-ING
PERMIT FEES
Plan Sets
Plan'.Chec-k submitted
Ilem
Amount
Structural Calcs.
Reviewed. ready for.torrections
Plan Check Deposit
Truss Calcs.
Called Contact Person.
-Pian Chick
ick Balance
Title 24 Calcs.
�Pians 'picked up
Construction
Flood plain plan
.Plhns resubmitted
Alechanlcal
Grading plan
2"' RevieA ready for corrections/issue
Electrical
Subcontactor List
.,Called Contact PersdIC
Plumbing
Grant Deed
Plans picked;up
Sm.l.
H.O.A. Approval
Plans resubmitted
Grading
IN' HOUSE:-
re o
ready foricor citi n issue v
Developer Impact Fee
Planning Approval
called Contact Person
A.I.P.P,
Pub. Wks. Appr
Date of permit issue
School Fees
TotalwPer.mit Fees
.7
7 it .1 1 — I /V
50�