SFD (0205-284)78900 Lima St
0205-284
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
740745 B
/
/Dated•,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 memployees with wages as their sole
compensation, will do the work, and the structure isnot intended or offered for
sale•(Sec. 7044,.Business & Professionals Code).
( ) 1, 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 V B&P.C. for this reason
Date y 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 37.00 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 %A,0,1X y*,A(Jy.1.V II*iSz Policy No. I S IS422dw2
(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/provisionvof Section 3700 of the Labor
"Code, I shall forthwith comply with those prpws ons.
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 upoq
the above-mentioned property for inysp�ection urposes.
Signature (Owner/Agent) / d •�..•• Date
i t BUILDING PERMIT PERMIT#
0205-2M,
DATE VALUATION p�¢¢ yy nn LOT ,00 TRACT
`
JOB SITE
ADDRESS �r» .�.
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CAIMTAL PAWAiC Hc9; MO `ihiC
' CAPTI, t L PAMFIC HrJWS .W 'r.•
4100 �tAQ t RTl'TUF,: DUD D 4200
NX -M ?ORT BF—A..£"H CA 926£)(1'
NEWPORT DRAT 'H CA 92660
"949)ra?? 0 wT %fir 1503
USE OF PERMIT
. SY0 L.% P1,N ihri' ,laialf::"a '14iii lAfwel.t%'1 ELK; .�'•.1',e)1La,4'PA-
0R DNA YAF' e,if.Ni IM., RE, At�t. 10,D P,%M 190- UAC 0364.5 ,
CGY:OTOLM CONSTRUCTION .%ranq ;lig
Pr#9IgtyC/;tP��Iti3g'1t!`s�'Ir TWA, 1322.00
1322.00
gSY
- 6 k't.f'�i.P1.Y.Pp•'J l..+.1 WIN 8p,
. C .#4R'"4:.'Jri.l
.
ESMIATIM MST OF CONSITUX110H
319110110
CONSTRUCTION FROZ lot -000-118-0m,
PLA14 rt Ix: ;lr.EY. 101 -000-439-.31 S gm. 47
I!1II;rvI•MICA'L .FEE 101-000-4.21-000 $125,00
WrITRICA11 PSN' .01-000-420400, $274.62
$ TfsOI*I':I 101.000.419.000 $326.79
STRONG MOTION YEP, - WMID 101-000-241.000 $31.98
GRl1.UIMFEE 1 it 1 e,OM42.3.00Q $111.00
lDs,'VE1,I)PEP IMPACT ITEC: $2,405.00
SRT IN PUEtUC MACES - ROME 277 0 000-445s'M. 0 �•c9$.43
,
al?F1 DEPOSIT3�� � its.ab
ITrlfi'US'i`iW1' 0IN rEE '10,14000-42.7-000 4000.423.0300 II1,71,012=
-�rv,..yy�
y .M. t, t
4,ITCt10R AtMPLAI'F? C"t�:rl c
$6,e71.99
CITY OF LAQUINTA
FINANCE DEPT.
RECEIPT
DATE
BY t"�
DATE FINALED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_C5
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
7
F.A.U.
Framing
Compressor
Insulation
,2 - Z
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
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
p
Heater Final
Water Piping
Plumbing Top Out
�Z
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
7Z
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Utility Notice (Gas) 77—
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) �� .�
Final
COMMENTS: (� C�
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