0205-266 (CPWU)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
.0 349,2 x`27 l V2a/2i
Date 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). ,
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER S'COMPENSATION DECLARATION IA
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..
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 ' is r9114S, t 10..E Policy No. "NO -M-3344
.(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.
i Date: ` Applicant
Waa:ning: 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 attorneys fees. d
IMPORTANT Application is hereby made to theDirector of Building and Safety
for a permit subject to ,ihe conditions and restrictions set forth on his
application. ' k
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. ,
t .
11-S4nature (Owner/Agent)
Date tr
PERMIT #
-BUILDINGPERMIT -..�; 1
DATE ` VALUATION y � 7 LOT TRACT BI 50A 'E 31 •fir 1 s
4 -7 •t ;2
JOB SITE ADDRESS 17- .1�VE=, '' V,,Q! fJ?ZF. A
APN 773-074-002
i
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C0AMW-U ABY: LTZKY.RFU ;A,i" O -R &PAX X
IFZ:91C, W. C.
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s 1410 .L�"t�rmao?�"
ZTDTO CA 92201 .
Lt, Qj,ikaq A. I (!A,,� 9221..3
144 8 07
USE OF PERMIT + �'
tom --imp 1�& Bmt)- wC"s
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D
SPEWS,. CONCESSION Sl l,�hID. C'W�AlY/.yAi T. 1111E � i Kui� AL9,V SHADE
V.f3,WA' ION Us
1109T OF CONFrRIMMON
2001000109
PLAIN CH. HK 101-000-4.19-318
XLM' RIMCA ISI, 1,01-000-1420-000 _ ._ $200.1m
,
.1C AND PLAN CHH �
M95.10
TAM" PRE"PAIDPEZ34
PXAL PXiSSh.F'Yd 11Is•CaS.P.+U'8:.206i'!+7
A1I5 n F 2902 `
CITY AF LAQUINTA
FINANCE DEPT
T
RECEIPT
DATE
eY:? •
DATE FINALED
INSPECTOR
F
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
veCombustion
Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_
Compressor
Insulation
L_/(Cff
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall 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
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping GGSS}eti) )J,t�rr
PLUMBING APPROVALS
Gas Test
Waste Lines
7Q f Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
7i ��
Encapsulation
Gas Tcst
Appliances
Final
FinalS�.✓�lj�v��'`—
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 _ Q�
Final
Utility Notice (Perm)
COMMENTS: /
O 2_
p Z c057 r.2 &6—
CoNc�y,,�,•' s
P.O. BOX 1504 Z O J —
APPLICATION ONLY
Building tt�� 78-495 CALLE TAMPICO
Address 77�-AVL 14Ay75y0444o4 LA QUINTA, CALIFORNIA 92253
6� Owner — - - - •- -
Address ,s0W'..g?/ �,�/ To/r! fir
City Zip Tel.
/�V//JVO 9220/ 3af�! -A49* I
AA &04467r
ddress
ty
State Lic.L 11^^ City
& Classif. �✓ I V Lic. N
Arch., Engr.,
Designer 6 ✓r llGhl
Address Tel.
74 1040 NW III T11 -mo -7
City Zip State
pLu I9��?' A'2/il../) Lic. a
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
1 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 e
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 70001 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).
I] 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
or improvement is sold within one year of completion, the owner-buildet will have the burden
of proving that he did not build or improve for the purpose of sale.)
1'I 1, 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 of improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Lew.)
i 7 1 am exempt under Sec. B. 8 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
n Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it 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, atter 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
Ihereby 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 if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
1 agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of attplicant Date
Mailing Address
City, State, Zip
UILDING: TYPE'CONST. OCC. GRP.
.P. Number 77-3 7Y'—y0 -22_ �(
egal Description ice` 130- /.?/ S G AV[.dt 4r
roject Description 4eo-~ S. te 4=7i ,
S, /f/ Sr /3
Sq. Ft. No. No. Dw.
Size 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 ND �ii>C POS i T PE1L fs
F11VA✓6E Td dl,4kE )OtXW#e- 1E.✓77L�/.
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 DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
YOUNG ENGINEERING SERVICES
Engineering Architecture•Surveying• Building & Safety Services
"Letter of Transmittal
To: City of La Quinta Date: 07/11/02
Project: 77-865 Ave. Montezuma
Attn: Ed Randall PC #: -0205-266(2 nCheck)
Tel No.: (760) 777-7012 Tract No.:
We are forwarding: x By Messenger By E -Mail Your Pickup
No. of Copies Description:
1 Set of plans
1 Set of structural calcs
1 Set manufacturer specs
Comments: Plans are acceptable
Thanks
This Material Sent for:
Your Files Per Your Request
Your Review x Approval
Checking At the request of:
Other
By: Eric A. Frenzel
Phone # 342-9214
47-159 Youngs Lane
Indio, CA 92201
(760) 342-9214
Bronz Young