PAT (0006-266)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.
M License'# Lic. Class Exp. Date
In _ -
3A7AR • s Cf 1 D03.024. 04/30/2(
r pate { - f.. Signature of Contractor
C)
co OWNER -BUILDER DECLARATION
,'
Thereby 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).
'• (�)
1, as, owner of the property, am -exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ,
C0 O I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner '
N
9)
Q WORKER'S COMPENSATION DECLARATION
pZ 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 providedfor by Section 3700 of the Labor Code, for the
_J performance of the work for which this permit is issued.
J( 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
Zpermit is issued. My workers' compensation insurance carrier &. policy no. are:
Carrier 'STATE FLAIR Policy No. 065yi5-98
(This section need riot 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 t,hre workers' compensation pprovisions of Section 3700 of the Labor
Code,, hall fo with comply with thio. a provisio s.
Date: 4 9 Applicant
Warning: Failure to secure Workers' Compensation Overage 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. �t
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,agreesto, & shall, indemnify
s & 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) '�? �/� Dated r'
BUILDING PERMIT, PERMIT#
DATE VALUATION LOT�x
TRACT
-
t
JOB SITE
APN
ADDRESS 4x9n Aw.An Comm-
OWNER
CONTRACTOR IDESIGNER /ENGINEER
+'
MfM lP[pAi
T0.yY M i73RA CONST. CO.
4.3-510 tv1L AN Cotar
566 W LtRGEON DDMVL?
LA Qti-1NTA CA 92233
COSTA,IA SA
C.A.
92626
(714)09.5493
' . CB1_4 4240
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USE OF PERMIT
plal0
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840 S.F..P•,I.;L MAWOOCD.PATIO COVER ICBG 5030
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PORCI•IIPATIO 640,00 OF
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E.S'i`dl IATM COIN OF COINVI UC'170B
9,512.00
1'F1M 1'1 %',T oS`UAQAA.L Y ,
;TAN CHECK RE 101 x,000-43941 8 �°f0. di1
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CONSTRUCTIO14 FEE 101.000.416-000
STRONO MOTION tE I?,'EBID 101 ••000.241.000 S.35
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WrAL 1'1RM1:C1I7TS DI.TE1' O
RECEIPT
DATE BY<',Z
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:
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Building 8i Safety Division
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, ,� _ . P.O. Box 1504. ,
Permit #:
4' _
78-495 Calle Tampico s , - w
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L`a Quinta, CA 92253 " - s .
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Building Permit Application. and Tracking -Sheet', LL - r
Project Address:
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Owner's Name: � ,X� � � �'" ` :.
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CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. i cLUMBING FEES
'ST FL. 5Q F7 T 5
2.$
ND FL. SO. FT.
PUR SO. FT ii
GAR SO FT •rG
BAR P -30 FT ,y
WALL SC FT It
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EST;MA'ED CONSTRUCTION VALUATION S
UNITS
MOBILEHOME SVC.
POViER OIJTLE7
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Net to ca ;:sea as �rcceriy :aa ra::.anon
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM SAN EVARCOOL 'HOOD
SIGN
WASHER(AUTONOISHI
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEOUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TEMP. POLE
KITCHEN SINK
ABSORPTION SYSTEM B.T U
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE. TEWPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. 4 c
BATH TUB
SO. FT...v c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. REBID ra 1v. c
SEWAGE DISPOSAL
SOFT GAR * X'.c
HOUSE SEWER
REMARKS
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UI70ERGROUNO
A.C. UNIT
COLL AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING,
DUCT WORK
ROCK STORAGE
FOUND. REINF,
GAS (ROUGH)
METER LOOP
HEATING (FINAL;
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
C1� yd.
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIOWS0UN0
FINISH GRADING
FINAL INSPECTION
CERT. OCG
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FENCE FINAL
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Maya 04...00....1'2:08p .....:.........:.Tr ad it io.^_'a"1..,Desigri :.Cente�........760-674-1668.... P...2..............
FP.OM : FCR PHONE t•!O. . `7604315605 mar, 03 2000 06:36AM PS-
Tony M. Ybarra
Constr Co. ilk
566 Sturgeon Dr.
Costa Mesa, CA 92626 f r
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