SFD (0301-027)`. 1 . ( LICENSED CONTRACTOR DECLARATION
I hereby affirm under'penalty of perjury that I am licensed under provisions of
H.• Chapter (commencing with Section 7000) of Division 3 of the Business and
04• W ;ti Professionals Code, and my License is in full force and effect.
.Z License # • Lic. Class' Exp., Date
674074' :E MC
Date _ fi w • Signature of Contractor_.•
OWNER -BUILDER DECLARATION
,1,,hereby affirm under penalty of perjury athat 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
contractor's/fo construct the project (Sec. 7044, Business & Professionals
Code)
O I am exempt', under- Section B&RC. for this reason
Date "' " �' Signature of Owner `
6, 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
S ption 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:.
•:tamer �qTAJ1t;F1J14.f :. Policy No. t1�Ci-133 2£t s
(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 California, and agree,that if I should become
subject to the workers' compen sationp`ovisions of6ection 3700 of the Labor
%Code, I shall forthwith comply with those prprovisions.
Date: Applicant,' .r
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 ursuant to
any permit Issued as a result of this applicaton agrees to, & shal emnify
& hold harmless the City of La Quinta, its officers, agents and yJ3e
2. Any permit issued as a result of this application becomes null void if
work Is not commenced within 180 days from date of.issuan such
permit, or cessation of work for 180 days will subject permit to c c latiow
I certify that l have read'this application and state that the aboveiniprm '
• correct: I agree to comply with all City, and State laws relating tote buildrnbTy
' construction, and hereby authorize representatives of this Cityao.hoIN
the above-mentioned property -for -inspection purposes
Si nature (Owner/A ent) - I., Date / . "` 4�
PERMIT"BUILDING PERMIT -
u
03
01�027
DATE VALUATION LOT TRACT
IT22 yy185ry;^Y .Aylld .gl� °•
-
f,q A
'
JOB SITE `
ADDRESS 79 '774 iiia'"d'TORDYdW %2.X5T
APN.
649 -IM -210
OWNER
CONTRACTOR/DESIGNER/ENGINEER`
1'D W2 Zr I3 tj ,,C i 3ui3 J l'
i3 4F t Coinp.'Cei €'1om
ZA C tP.11TA 0,_4 92253 a
7.:.A QVI zA CA '197253
C?60)171-1 %4,1 ?' Cavi 2996
USE OF PERMIT
SFr,% -1. &f 41, K AN X1: PeRmi'J' ,i1cip NoT 21b101,FtiC)z 131.OcK w, ,:. '
12.EVOCTIO)4 FOR. MUl..'1'i,Fi i<w I:arWANIC f1 OF SAME P1:.1IN 'ryn ,
CUSTOM CONSTRUCTION 2:o3 .i u Ski
{:
.x5i°:t ma) CC3r, ' or cfinirRdlenE, m
.220 1V
�y
WAST RUCT1ON�YRZ 101.a000-418.0011
PLAN CHECK FEE 101.;0-00-439-318 4 het m.�3{f
101-000,421-000
'" V,CTRifi.A160 FIU X000-420-11f?,'0 �162:t33 .
.101
PLUMBI-r�11 ix1s 11r1;0i�0�41 �nt10 $.1' odti
Fi'£RYaWC3'ViOT101+1N- M—REBID 101.000-2.41-000a � $3z:09
GRADING FVKE° 101-000-429-000 V51102
ART Yiq PUBLIC PIAC'F - i iC 270.000-445.000 41. sn o
tp::.9
C C.NI Clot:YMION A31417)y�?Z,s�t+1ISS
�'a.�,22.38
1q
�1'q". y ; ry p��j�{
'
$0.00.
L
INTAII IMES WE NO. NY
2 2., 2003 .)F
LXQUINTA
NCE,DEPT.
RECEIPT
DATE' '• -
BY
D INAL D
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
; — Z —
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Insulation
y_ Z _
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
_ _
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
7> — j
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
/
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
1-31-3
Encapsulation
Gas Piping
_
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) jC 3
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)