RC (0310-236)78065 Main St Ste 100
0310-236
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am•licensecl'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 Cf ^'"6 Signature of Contractor,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
r, Lcense Law for the following reason:
1, 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:
CarrierSTATE FC7RD...P,olicy-No..__
(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
i'm
workers' compensation laws of Califoa, and agree that if I strould become
of
subject to the workers''bompensation provisions of Section 3700' the Labor
Code, I shall forthwith comply withI ose,provlslons
/Date: iLlILA Applicant
Warning: Failure to secure Workers' Compensation -coverage is unlawful and
shall subject an employer to criminahpenalties 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
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, indemn
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and voi
work is not commenced within 180 days from date of issuance of su h
permit, or cessation of work for 180 days will subject permit to cancellati n.
I certify that I have read this application and.state that the above informatio
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 LL -'t 413
r @ SUILDING PERMIT _ PERMIT#
06. W-236
DATE VALUATION LOT TRACT
JOB SITE ✓ , ,
ADDRESS Qj MA7`Eq r 'iJ R,i • E. L%
APN
-
OWNEER`
CONTRACTOR /DESIGNERENGINEER
LAi i HOMES .
ydJMVYON LYMA SYyCNINC
78.060 CK + ' tD'203
78401 a 1 ,iG:l'•3tR1AY 131; 3=1 1.-2,
LA ' CA 92253
UQWLLMA. ; CA 92253–
(760)771=•3593 C"a.W 5330
USE OF PERMIT
00M1a MZCIAT, ti.>wtFilOL➢EL (JAZZY'S CAA' •& Ce4.'1'ERMO)'S' OCCUPANCY,,
TYPE V14 SPRTOKLED, 00CIiPAs7'I''LOA:D48, 2001 CDC INVIM 1 AY1ON
IFEE ASSESSED PER 1997 CftlxsFOliM ADMINISTRATIVE A.T.iVE CODE SECTION
COYTIZAC"'T :€>iMO'MIT '75,114.00 LS
19TIlMATED COST OF CONSTRUCTION
FmImn,'Firac, SUMMARY
CONSTRUCTION RE 101.000.418.0W U31150
PLAN CHECK FEE 101--000-439-315 t4m.52 `
MECHANICAL lANICl. L .FEE 101-000-421-000
Zi..EC' aIQAL Fa? 101-000-420-000
PL1JA+iilANO FM 101 w000-419.000
STRONG MOTION FEE - COMM 1t70 -00a•241-000 .. $15.90
IN'>MSTIOATION ME 101-00 0-423-000 $60.75 .
e , ( At' "k2CJLaiT04J' 1 3713 px m- c
$1;9B3,Gta
LEIS PRE -PA I'M
$0.0
a0U 14.1003 ,. ..°c 4AL >P11,: t rrrT'VEMS''Uri Now,
CITY OF LA QuINTA
FINANCE DEPT.
RECEIPT
DATE /
BY / .
DATE FINALED
INSPECTOR
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
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
Utility. Notice (Perm)
COMMENTS: