0208-304 (GRES)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.
License # Lic. Class Exp. Date
674074 IS _rv,er�
,.-Date Signature of Contract�orw I
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.
FK 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 '011T TE FUND Policy No. 1jej6.ta�41i►i1°it,t�
(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-601liject to the
workers' compensation laws of California-, and agree that,if I should become
subject to workers' compensation provisions of,Section 370%f the Labor
Code h�s,,,,��ai odd L comply with those provisions. /�
Date:J+�� s Applicant �•�-.•rt C--..�"`.�'
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 subjectpermit to cancellation. x?
I certify that I have read this application and state that the above information is
correct. I agree to complywith 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 purposIs.
,V',
Signature,:.(Owner/Agent) - -� L� �� Date
BUILDING PERMIT PERMIT�#�
DATE ^ '� ,I VALUATIONy� LOT TRACTJOB SITE
255 t
ADDRESS ;i.i iF3.f.17'Ai4dd�BS�l�lcw.2,�.1' APN, C�.�"�^�'�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TD 3YE`,Ea:']iEVEILOPI&W3' �'"P.t' RKS CORfii iUC0DI:Y
LA QU.WVA CA 92M LA. QTNTA CA 92253
(. Ct3)771.1941 c' lip 2996
USE OF PERMIT
YUPPLl'r'e!9'lyNTAk,'SOPER1 IT410111d210:162,aP ,e'i.R`f'GiA1:.AW.
NO." aITION TO O?'1ACHED GURST SUITE, �:it,►�UNO Ilii t AJ,, C0114,'t f UCTI�3,N
v.i
0ARAC49CARPORT 162,00 0W
1.181DIUMD COST OF CONS'1:'�`VM1 1 ON
r F) E119 Sul 0_1 ARY
PLAN CHECK M. TA0,9
CCY: tS R1JCTIDX .07LE. I 0 _ 2004. } 8.000 $53.C.a
S"`I'1i;%°.,NCr MOTION 11?YZ , A&SIO 101 ••(d!,10-241-00.0.) 21.50
ART 1A?; 'U.TJ1,IC.' PLACH.8-17.F.bSK 270-000-445-000 f 97.44
311751.9
SUMN t7N 1) )LAY CEMCK
All 11
CITY ®� LA QUINTA
FINANCE DEFT:
j,.
RECEIPT DATE BY DATE FINALED INSPE
�d INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
—
Ducts
Slab Grade
Return Air
Steel
— 1,9 -0�7,
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
--2 6�_
Compressor
Insulation
f
Vents
IZ
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final —
Final -T7-
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
9--/119-
Heater Final
Water Piping_
��
Plumbing Final
Plumbing Top Out
!�
Equipment Enclosure
Shower Pans
ZZ
O.K.-for Finish Plaster
Sewer Lateral
Sewer Connection
_
Pool Cover
Encapsulation
Gas Piping
Gas Test
,
Appliances
Final
Final _t�
Utility Notice (Gas) —�
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring _y
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles 5
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) ,
COMMENTS:
rin # V,� City of La Quinta
�. Bw7ding ar Safety Division
�(e P.O. Boz 1504, 78-495 Calle Tampico
Permit # �.'` La Quinra, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Project Address:?9(o(Z ,t/%/SS�o-✓ Qi1ry z,M j Oµ•ncr's Name:—, D p�
A. P. Number: Z Address:
Legal Description: 7X X7. 24K -9i -L Z.,,-7 �S' Cin,.ST. Zip:
ontractor:Sj,¢2lCS co/A)16--
ddress: P Project Description:
it.. ST. Zip: G z Z !�;7 -3; = 2,D
Telephone: 7-71—t9%41
-S S
State Lic. # :6, D % y� `City Lic. t: Z `/(P '
6LRAGb "P, 17 a
Arch.. Ener.. Designer: S
Address:
Cit}. ST. Zip: Olt -Z
Telephone: Construction Type: Occupancy:
State Lic. it: Proiect type (circle one): New dd' alter Repair Demo
Name of Contact Person: il%ocAnt SPK S Sq. Ft.: / Zo Ib -_7 u Stories: a Units:
Telephone # of Contact Person: X77/ -/ `Iell Estimated Value of Proiect: /7-d>00
APPLICANT: DO NOT WRITE BELOW THIS LINF I
M
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted .
Item
Amount
Structural Calcs.
Reviewed. ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan heck Balance
Title 24 Calcs.
Plans picked up
on ruction.
Flood plain plan
Plans resubmitted
Iechanical
Grading plan
2" Review, ready for corrections/i sue
EI ctrical
Subcontactor List
Called Contact Person
mbing
Grant -Deed
Plans picked up
M.I.
H.O.A. Approval
Plans resubmitted
rading
IN HOUSE:-
Review. ready for corrections/issu
:veloper Impact Fee
Planning Approval
Called Contact Person
A.1.P.P_
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
4