SFD (0301-029)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
1-- esChapter 9 (commencing with Section 7000) of Division 3 of the Business and
N LU .`.: Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
�W
o Z Date ' '�.- Signature of Contractor• "'`
^'`".-
U CD, OWNER -BUILDER DECLARATION ;
y -
LULU ':.I hereby,affirm under penalty of perjury that I am exempt from the'Contractor's
CL
CD •: License Law for: the following reason:
Z_` t ( ) 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)
as owner of the property, am exclusively contracting with licensed
contractors to"construct the project (Seca 7044, Business & Professionals
Code): 'F'
c'')' O Lam exempt•urider Section B&P.0 o'r'this reason
,•.U5 r. -
N Date Signature' of Owner
p t.
U Q WORKER'.S COMPENSATION DECLARATION
C> I hereby affirm under penalty of perjury one of the following declarations:
p O 1 have and will maintain a certificate of consent to self -insure for workers'
K, LULL compensation, as provided for' by, Section 3700 of the Labor Code, for, the
J Qperformance of the work for which this permit is issued.
Q 3 ( ): I have and will maintain workers' compensation insurance, as required by
S¢ tion 3700 of the Labor Code, for the performance of the work for which this
i ori H ', permit is issued. My workers' compensation insurance carrier & policy no. are:.
�.Z Carrier .KAT'EP:t.9ND Policy No. �lA�i•:13"+�•2.l��
g(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;
1 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'
3 x subject to the workers' compensation,prouislons of;Sectio�3700 of the Labor
Code, I shall forthwith comply with•tliose provisions.
Date: ,, . Applicant
lb -Warning: 'Failure to secure Workers'' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost.of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
-IMPORTANT Application is hereby made to the Director of Building and Safety
for,.a permit subject to the conditions and restrictions set forth on . his
application. ;
1. Each person,upon whose behalf this application is made"& each person at .
whose request and for whose benefit work is performed under or pui
any permit issued as a result of this applicaton agrees to, & shall; ir nify
&'hold harmless the City of La Quinta, its officers, agents and em !Tees.
2. Any permit issued as a result of this application becomes null an IlVilid if
work is not commenced within 180 days from date. of issuance 0(( uch J
permit, or cessations of work for 180 days will subject permit to can dila ion.
I certify. I have read4lils application and state that the above info,
ati
• correct ;I agree to comply with all City, and State laws relating to the building IF
construction and,.hereby authorize, representatives, of this City, to en
the above mentioned propertyrfor..inspectiron,purposes S '
Signature (Owner/Agent)
BUILDING PERMIT PERMIT#p��yygg
}!�'�y�gg �) +�
DATE VALUATION qwq 66 1jr� (/��q�yy LOT V] TRACT 22457-3—
,» M.Ae�L74S. 4.6717 �:✓ 224JAY ^.7- ' t
JOB
JOB SITE °
ADDRESS 79-1159,11A,^SSIORDPJVF,E,$ ffi
APN
�•}.Rii�-
OWNER
CONTRACTOR /.DESIGNER ENGINEER
TD 3�11;.�,'il.�'3. DE4E•.t1T raT
SPA#7,i'CS CoMr-pl J GrI: � M
;Pt: BOX 1715
%'9-2� r,.t�F7Cl1TY).1 Qc7�a%A1Xt
lgDVINTfa C'A 02253
Lt'O•C17NT-A . CA
- 4 .3
USE OF PERMIT
;..
'm - Loro. Pl." :a?, niamff Orel 11MT ,kr; US,
P001,,SPA C?R.DRIVEW-A';;` Afby OACH,, 7.�% i'.3,,AN CBECK ME `s
'&2.EF.�I,JGT'tS3� lj�i7£ fk4i�tY.'><'t;•rL� 1S51i.>~riC:'L', R>`'P''�.�i'2�� I'Ln�1,'�1 TY:T�tr ;' +, �'' 'z.
Ci%SiT_3M C ON 1''RUC T XON wmoo 017
PCIRCHIPA IO 267.00 Sit'
GAR 4 9MAI2PORT 614,0 i .SF
WD
C.'ONSTRUCTYON VKL? 10)-{COQ-418� ,000 sjjmr3.ato
PLAN f"NECK 111VIA $217.94D
1Jj�Gt'� FaNl�.4ht,, IAC#, Y O1 •�UOC'.l!�?+� rarJCit1 $�1'iur(f4
: "
7rwl;f?.C'�'k2;K��t,.t,f�'�h ����c�t�o�4.ac�••�r�ef .. �I��.fea
P3,iJMBIN0 FEE '101.*0004196000 SYM2$
STI•t"O `NO MOTION .M • RY-3133 101-00,241-00 t��4:fJg
ORADWO F911 101 -000-423-000
ART IN PUBLO PLMMS - 914M 270-000-445-000
o7Li,L%'.b'`}'�.l , CO 14811M 1` r�JiY'.aP, h.l�'.v .i' ...13.1;�i �:J:1S.•1.:is
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TOTAL3.. 1��" R~. EES ]JUT HOW
22 2003
s� t
t �
! Of' LA QUIN IA
I<.'ANCE DEPT.
..
6
RECEIPT
DATE
BY
DATE ALD
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_ -
Return Air
Steel
_ v
Combustion Air
Roof Deck
p _
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
-3
Compressor
Insulation
—
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
py
Fans & Controls
Party Wall Insulation
p'
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final�_��
Final
49 —,)- 3,�S
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
3O—
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
/
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
p — j
Encapsulation
Gas Piping
Gas Test
l -
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
3,11
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)