SFD (0111-230)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
67r� 74e
Date,;7:d`r , Z Signature of ConiractoF ! dw
OWNER -BUILDER DECLARATION i
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. � f,P><`i . �' Tt'E1� ft ie' 4�r-�?17338
(This section need not be completed if the permit valuation is for $100.00 or less).
(') I certify fha(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' compensa`tio pYovisions of Section�3700)of the Labor
Code, I shall,,forthwith comply with those provisions. r
Date: ; r,) -'L Applicant V r'
Warning: Failure to secure Workers' Compensation coverage is unlawful ankd
shall subject an employer to criminal penalties and civil fines up to $100,000, In
addition to the cost of compensation, damages as provided for in Section 3766
of the Labor Code, interest and attorney's fees. /
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at.
whose request and for whose benefit work is performed under or pursuant t
any permit issued as a result of this applicaton agrees to, & shall, indemnif D
j& hold harmless the City of La Quinta, its officers, agents and employees
2. Any permit issued as a result of this application becomes null and void i
work is not commenced within 180 days from'date of issuance of sur
permit, or cessation of work for 180 days will subject permit to cancellation
I certify that I have read this application and state that the above information I
correct. I agree to comply with all City, and State laws relating to the bulldln
construction; and hereby author,Iie representatives of this City to enter upon
the above-mentioned property)6r inspection purposes.
Signature (Owner/Agent) " DateL LJ
UILDING PERMIT PERMIT#
DATE VALUATION
/ rye ray g ry y y� LOT TRACT
JJ{(),
} S240,117-1029457-2
JOB SITE
ADDRESS w6pPs v"bast�C� � iA l �. +5
APN
,-2.(n4007'
OWNER
CONTRACTOR/DESIGNER/ENGINEER
PO .LYOJ1, 1716, E
79.2.95 !2MC T?O 1.A Q'. IN T'A DR,
,A QUIN`.f A �" '� Q21.33
� QMTTA :CA 92253 . .
C760Y -1941 0T.0. 2996
USE OF PERMIT
6Sf�'L,7d,ai°
wa b� . 1.A.P? fd ]!'R,. n?w t�dt7' ,iiJF. t ii'7' INCLUJX H Lf"2yi�'�U')i I .,
P =4 SPA. OR. DRIVEWAY APPROAH
CU TON CONSTRUCTION 2,92411.4i V
k��Cpi��ty�rk/ii.F�?;arlt,°tp'IQ �Ad:��5q:ip�0
(3F
qp�
�..W1t9-WEi0.•.P� RPOi, `1� 0,00 Awl,
ESMIAM V0,1791r CDB.s' Cl' ,11S'$ RUC:4.105
240.117.20
C90"t"tMIRUCTION FEE 1..01-000.418.000 816133,00
PtA14 CHIDOX IeEE 101-000 ,439-318 $732.24
NECHAN14:,41, VRi, 101.000.421-M. $130.50
WE? 'Z KIA.1. ME 101-000420-000 $169.24
NLUMBINC FEE 101.000-19-000 $175M,
STR.OUD MOTION M - RF -SID 7 01 -OW -241-000
234000 g za,nu
PADTHO V ; 101-000-423-000
DXVV,WP13A 1M1'.s Vi' F2- $i,9ttY:b
`i' IN PUBLIC P'LA RUM 270•-000.445.000
- € ' 610).*FRTJ•C"'i':LM .AND PIAN' N' WFUC.s3,nnx
MISS PRE-P-11METIM
y
$0.00
g��
DEC0 6 2001 TVAL?ySd .B: A•5:61.Y'Arf IM0rS' LFTJ.9 AYO
&41892103
MYOFT.AQUlNTA
FINANMYEPT.
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
a/ _
Return Air
Steel
5-% - Z
Combustion Air'
Roof Deck
-7
Exhaust Fans
O.K. to Wrap
` r-
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
',J_
�2 �"f�
POOLS -SPAS
BLOCKWALL APPROVALS
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
�/ - zc�i —Z
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
COMMENTS:
Final
Utility Notice (Gas)
�-
� -' Cm -it
_
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
f �,
Utility Notice (Perm)
/ -