0111-039 (AR)77385 Loma Vista
0111-039
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 „; Policy No.
STATE FUND 498-M43NIT ;105
(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 mannerso 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'sudh
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 1r F - TRACT - Q"
JOB SITE APN
ADDRESS 77-51L5 LOMA V137A W. _220-0017
OWNER CONTRACTOR / DESIGNER / EN (NEER
; OMT I,ZMEI IR OWNER.-BICIER W. Wf.53 KMIS (:1OMP
1A Q-01WA CA
USE OF PERMIT
ME)EN'3.`'.Yf.'sL fiD b►MOW
BATHROOM AI)rX71011H
CUSTOM CONSTRUCTION
102,00 OF
Mi''ll.M..MD
COST OF Ci: NRYAUMON
19 *.W
YFX NOWAARY
v312wx nr,f
101 * J ►Oa4. ! 8
G4.,f
CONS'f`3 i.DMON FEE
101 _000.418_000
; 99, f3fi
ME';t;HAHICAL mhr
R ti 3 tliY per? 1 «E}iZt7
30,aU
4''.I.Saf.:TAICA -1i FF%
101.000-420-
PL13 +-' NNO PFIX
101.000.419 -NO
V4tif. NOL MOT1014 FEE - AMID
101-000-241 ••000
$.Ta
'1.'CiTAL': PERWY' VMS DUE I aOW
PT I DATE I BY I DATE FINALED
INSPECTOR
$2".14
3,(50
&9*4.14
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
_
Forms &Footings
Ducts
Slab Grade a`i
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wail 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 Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines! _ (
Water Piping `107/
`L
Heater Final
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. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Trimp. Use of Power
Vinal
Utility Notice (Perm)
COMMENTS:
77385 Loma Vista
0111-039
Lhereby affirm under penalty of perjury that I am exempt from the Contractor's
1.,A
U)
License Law for the following reason:
PL. AN t J)ECK, FVC-
Z
( ) d, as owner of the property, or my employees with wages as their'sole
+
E
compensation, will do the work, and the structure is not intended or offered for.
101-000-4 18-000
$99.0
sale (Sec. 7044, Business &Professionals Code).
USE F PERMIT
;»L VIC; i rid
( ) I; as owner of the property„am exclusively contracting with licensed
nt• i :” -I
contractors to construct the project (Sec. 7044, Business & Professionals
I ':,'Jfi'1t~$0=-OX-420-000
Code). (- _._..., _ , ... --,,.,, VA'fkiiR0C,};t+5AD1,12.
N ( ) 1xam exempt under Section B&P.C. for this reason `
t t
~ . Nate Signature of Owner
rn _
U—d Q WORKER'S COMPENSATION DECLARATION
Lo Q 1 hereby affirm under penalty of perjury one of the••followiKd'declarations: CUSTOM CONST't!d;310*1
r. O (•) 1 have and will maintain a certificate of consent to self -insure for workers'
'X W' compensation, as provided for by Section 3700 of'the Labor Code, for the
Q" performance of the work for which this permit is issued.
'm Q- U ( ) I have and will maintain workers' compensation insurance, as required by
O•U Q Section 3700 of the Labor Code, for'the performance of the work for which this
d H permit is issued. My workers' compensation insurance carrier & policy no. are:
tiA
PERMIT # y
TRACT
r
1"N
CONTRACTOR/DESIGNER/ENGINEER e
102,06 8F
.`t Z
Carrier `""" ' eTE tf+ )ND 'Policy No. 4 ' •YiR-t2t31
: ) CO'W'r OF CONSTIMMION
' .,:4
(This section need not be completed if the permit valuation is for $100.00 or less)::-
PL. AN t J)ECK, FVC-
t G3 -C+O -439-. Ifi'
+
() I certify that in the performance of the work for which this permit is issued,
X)H,`.;'TR.! t°V(714 IPFE
101-000-4 18-000
$99.0
.,
I shall not employ any person in any manner so as to become subject to them
;»L VIC; i rid
101"000-421-000
030.00
workers' compensation laws.of-California,.and agree that if. I should become
I ':,'Jfi'1t~$0=-OX-420-000
$300
Subject to the workers' compensation provisions of Section 3700 of the Labor
3
C? Jel shall forthwith comply.with those provisions.
YF•,tut A )a .ir'.
+ lcsi'c €lzlwA' aoOCf3
30'0c
ate: ., t Applicant's -,•.:
LLx'I?A7NGMovow ri7?E: -Stl:7 l01_-:00P-241-l,;t"i 2
•'W
i
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 _ NOV1
application.
1. Each person upon whose behalf this application is made & each person at tlf
whose request and for whose benefit work is performed under or pursuant to
any
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
thea ove-mentioned property for"inspection purposes.
r " • ^;, 1 RECEIPT DATE
.Signature (Owner/Agent) ` `• .^w Date r t f
v > a
At ID PLAN 0 MCK
lZMS FRE -PAID FEW
DATE FINALED INSPECTOR
7,5935,4i..
i
5:244,14
%J A
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
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 I
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. 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
COMMENTS:
'