SFD (0111-231)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
/
Date��.. ;�� Signature of Contractor
OWNER -BUILDER DECLARATION/
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: w
( • ) 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 STAYE.F IMOD Policy No. 49& 9 +'VA33i3
(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 Californja„,and agree that if Irshould become
subject to the workers' compensation `provialons of Section" 370 of the Labor
o !. .
Code, I shall forthwith comply with those provisions.,:
Date:���/Applicant -'
Warning: Failure tosecure 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 oK his
applicatior?. 34'
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 employe
2. Any permit issued as a result of this application. becomes null and Vol
work is not commenced within 180 days from date of issuance cf s
permit, or cessation ofworkfor 180 days will subject permit to canceHat
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 buil 'ng
construction, and hereby authorize representatives of this City to enter:u on
the above-mentioned propertyFfor in ° pection purposes. '/
Signature (Own
BUILDING PERMIT PERMIT#
DATE j VALUATION LOT 0111-231 TRACT
to :2911579
JOB SITE
APN
ADDRESS 7t... �5a4 ,om� �
S�-Y.f�(p-007
OWNER
CONTRACTOR / DESIGNER / EN (NEER
"ED M,'� ,. 'TD3l:` s<.OY1411'1k ,
PO BOX 17 416
79-295 PANU.550 LA QUIRTA AIL
7A QUi.ZZfiAt,. CA 92253
1A QLi'O TA CA 92,253
�36(j1'771-191 C.`,l�G�12.99.
USE OF PERMIT
R Cr3 E FANMY -DWM :d.WO
K1301,45 PA. OR DRIVE—WAVIfiPPROACH
MSfOM C OM°.4'1b,UCTION 2,924.00 SIP
1%C3Yt.CiYIY�tY�'iCf 233.00 SF
(3A1tA0WC&R,P0TtT 470-00 SP
ESTUAMM C.OM tial t"C2SM1°c7:tiUMPT
240,11.7.10
YER:M(F FEE S'1i"Af6MmZY
CONOTRUCT110)4 FEE 101.000.418-000 0,133,00
PLAN CHECK 11*3 1€31.000-439-318 $832,24
MV_CJ4J1a?YCA,E.FFY, :01«ULO-421-000 110.30
X3..f?,:»`!'€", coil. F3}. I til »000»420-000
PLt'fs'o'31'lIN10'FE&Z 101-000-419-000 R3 :
STIKMG!MOTION Yr' P -' :31]D 101-00=41-000 9i�b Od
�3ti AD1..140 FE 1131--1100.413.00. 0 !1 4,p9•-
ARTIN PYl.13r'.'. C PEACES - Mt?; .VIO-C 00-445at` 00 ff 00.29
#17:e -Tod .L Ci' meartaTMOK ARD PLAN CMCK
I.,FUS PPM -PAID P7
$0,00
DEC 0 6 2001
MYORAQUINTA = A; -
DATE A i/
DAT'FINALED
.V
INSPECT
i
a
,,_
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs—/�
Underground Ducts
Forms & Footings
s-/(9 Z
Ducts
Slab Grade
_ _ Z
Return Air
Steel
Combustion Air
Roof Deck
p2
Exhaust Fans
_
O.K. to Wrap
Z
F.A.U.
Framing
V;J y_ _v.
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/�
�Z
Final
,J
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 I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
_
Waste Lines
2-- 1114�
Heater Final
Water Piping
Plumbing Top Out
_
'r�
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
y —Z3—Z
Encapsulation
Gas Piping
Gas Test
O��
Appliances
-
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
, /y —off
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
%
/l
Utility Notice (Perm)