PLBG (0207-183)LICENSED CONTRACTOR DECLARATION ;.
I hereby affirm under penalty�of'perjuiry 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 # (Liic. Class Exp. DaajteepNq
46
Date " --" Signature of Contractor -'-2 t , 62" d f
r"
.OWNER -BUILDER DECLARATION
1� 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),
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner h
rn _
d Q WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
4, r O(_) 1 have and will maintain a certificate of consent to self -insure for workers'
>' X US compensation, as:provided'for• by Section 3700 of the Labor Code, for the
yc. O � Q performance of the work for which this permit is issued.
m QU p( ) `I have and will maintain workers' compensation insurance, as required by
U
O ' Q Section 3700 of the Labor Code, for the performance of;the work for which this
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:.
? Carrier '81T ,TI;'ff' WD Policy No. 1641724
0 O
J (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,1 shall forthwith comply with those provisions. f°'y
e w. -' Applicant w r ; 1 J A
Y
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.
N..
IMPORTANT Applicatio6 is hereby made to the Director of Building and Safety
for a permit, subject to the conditions and restrictions set forth on 'hiss;.
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 for inspection purposes.
Signature. (Owner/Agent) «b f�- r� •�_ Date--'7-
t01
ate"'7 t0 >
- PERMIT#
BUILDING PERMIT', Co17�9 �•��
DATE, VALUATION` LOT TRACT
JOB SITE
ADDRESS 534%1',59 A �i l+:�i d� l
APN _ +
OWNER
CONTRACTORDESIGNER / EN 1NEtER�t
r7�y t ywsr
i;/
53-36 5 AV NMAI&M—) OYA
!,A Q',TMTA t CA. X25 y
PALM aPRNGS CA 92262
It
(760)320,,2385 CM* 7
.
,USE OF PERMIT
FLMft' ' 4
INSTAi,1.+4'& ICYN OF 5WLAR FOOL Kh• , ,` NQ .37' ;,T&M
' f 1.,t3 T30A; 1.800,00 LS
i:4 'STA 1.1;sR,/ WST OF CO1,��,C.RZl4r.dIJO
q w �s•�-� � � {{-- ��;xx g � rg�,� �. �{`,t yA},
.A.".63e.IR:•rrlNG Sc�.N. _fi + i�+RJJ1?*f�Y'�]1:74� ,
,
'PLUMBING rt � tCbp �(1f3ii 11 i.3�)On� $19.30 .
�ry 'a"9 -�.�V Yx�il..:4,.{,JIY.i.J •F,A�..,.•.L'a AEV,�.+t^dt!�+1,.[4.♦+tA�Eit��.1:7G/.+A.:+•e��y.+. •t' r�
T-40.45
.00
_ t
'
eL
CITYOFLAQUINTA
' FINANCEDEPT.
n,
RECEIPT
DATE 7
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:
T'
Bin #
Permit #
FProject Address:
A. P. Number:
City of La Quinta
110ding 8r Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 . (760) 777-7012
Building Permit Application and Tracking Sheet
CW A o 2- %} Ow-tcr's Name:
Address: S 33 6 rJ'?�•o� ?-+4
Cin. ST. Zip: qu'& TM t <
,Contractor: ;50C.4 -f- (g Sq—A4 ;,vTDM )N�' • Telephone: s�o 4 " O C. t
Address: �oa� M� a Project Description: SOLt/� Sw I
City. ST. Zip: Pp,.,�.. S-�}- , '(o 42 2 foo'
Telephone: 3 �-• 3 S^
State Lic. # : re '7ZZ 1L 1 `Cin• Lic• t: r 0
Arch.. Ener.. Designer:
Address: S A,
City. ST, Zip:. a t c 0� I
Telephone: ;. :<:.? :: Construction Type: Occupancy:
State Lic. #: Projeci type (circle one): New Add'n .alter Repair Dcmo
Name of Contact Person: �' t,c, r, k O Sq. Ft.: 3 $ S^ Stories-, Units:
Telenhone # of Contact Person: 17-4, 2 3 it S Estimated Value of Pro icct: 38a O pa !
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cafes.
Reviewed. ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Pian Check Balance
•
Title 23 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review. ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
SAt.I. .
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
So LAP-
-
AiZ �t5 �RlBtrtRS, I t.�C. '
• r _ ,. _ • • ',("'icy ��' ► �+}:?A.•� . • !� �� -r" ` i •'`. , . iQOj M�L •A�L "r „' , '� 320 '�$ rj
61
.4 _ ' , ,CA4t�'�S�¢►1.LCa5, C� clZ.z(oZ
'j�� ' '[ s'-0 fid'... ! • u`
o Qw,' 4 A RE -INSPECTION FEE OF $30
WILL -BE CHARGED IF THE S
r APPROVED
PLANS AND JOB'CARD�ARE NOT ON
4
THE SITE FOR .A SCHEDULED
INSPECTION
NO TIONS.Co
.
.FoR: � �' S �• :�� • 53�3Cprj �1EtJ��A �E �a � ,.
CITY O F.. LA Q U I NTA
53 -3(o5 Aqi M�.1�o -•
BUILDING & SAFETY DEPT.
APPROVED
FOR`CONS TRUCTIO,N
. DATE
2-5 OZ• BY
-A
C
-ADOITION -1
C.T S
MIN
Installation out-,,�
nitallai cOrftp et0d on, orab:
tabout.`
P
'6nsbere d et tsalter-,th- anl On of;$,� �� `' �` }
Thdbu�er agrees 0 11.,,thelte�.ms�and bh1dit In.an ag-r s q- aya �t
sjt;
(40, 6q 40
OPP
%
1.1®r"O
r;n6Untih§ Of equipment,
UYE RtAID-" IN --A Ll-
0 KFO E,
A
FIACKNOWL#bG$�
-SO,$IqNV,'BY T-M,
A 42-,
AND, Al*,. tHf5,A0AfE-MrvT!, 'Iddoy'WAS,AL F(tTQ,
TM
::�m U Tv,Hf�-Sl NE,
0,N T, T A R' ,C -T, N EQ'C
is fl� HAS I�ECEIVFM A :C'O,py OF. E%�y H ING 'T TFIAC
MN. RSOVE jiUOTE 0600 �,b
BUYER:
T
SALES REPM "'T.IVE.,
Sal
fPI k'
I "