COMM (0202-239)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:
( ) 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 Is
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.
S c(,) I have and will maintain workers' compensation insurance, as required by
tion 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 w°, 11!` • Ps lit' Policy No. 044-:19A?M
(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'
'compensation provision of Seddon 3706 of the Labor
Code, I shall forthwith comply with those f'r+isions�
Date:�"?�`� �� Applicant P
�..,
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 subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above- menti oned,proper(y for i speetion purposes.
Signature (Owne
- BUILDINGRERMIT PERMIT#
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DATE. VALUATION- LOT TRACT
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JOB SITES
ADDRESS -898 IWISS"N.uff ARM. EAST
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OWN��Ess'ppR��T�t�TT
CONTRACTOR /r DESIGNEREN 1NEE6ER(�y�
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P0.80X 17 16
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USE OF PERMIT
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IF, PATIO
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PLAN- CH.WK PEEK 101-4)00-439-313 $174.90
MECHANICAL, WRE $20,00'
EJ,J 1'h.;CAL VIA. j.fl1�i3!?�J-�,�1-��It3 fi�2.kat
PLUMBING FIM 1041-000-419,,000 V !21150
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OR ADFIRI RE 101-000-423-000 $20.00
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ART YN PUBUC. §'l:allCER - COM 270-0 00-145-000 S41.27
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BY '�
DATE F NALED
INSPECTOR
_1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
l%_ (p p
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
- -0.-_
Exhaust Fans
O. K. to Wrap
p
F.A.U.
Framing
Compressor
Insulation
_
Vents l_
Fireplace P.L.
Grills
Fireplace T.O.
_
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-
Final=l G) 3
r
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
O -/ ��
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
j0 Z22 - 9- S
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 7 -
Low Voltage Wiring
Fixtures
Main Service _
Sub Panels _
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) _
COMMENTS:
Bin At
'
Permit #
W ��g�
Project Address:
CI Of � •
City Qu/nta
Building dr Safety Division
P.O. Box 1504, 78-49S Calle Tampico
!a Quinta, G4 922S3 - (760) 777-7012 '
Building Permit Application and Tracking. Sheet
et
�4 t Owner's Name: X •%n /,c_D
A. P. Number:
Address: X /lb 9 / 2/ �
Leal Description: 7/14CT ?
V'57 -
Cin. ST. Zip: X 6--P, -6-1 2 3
Contractor: 1(j'//,,�lL/� S ( rj ' j /V L-
Telephone:
Address: 9Q g '
Project Description:�
`- o
x gid«-
Cite. ST. Zip: y,L•� _� 2 Z 3
yi �v �i 7 S 7-Q ?/o !✓
Telephone: X -7-7 1 --i t'/
State Lic. # : X- '7(:1-,�2
Arch.. Engr.. Designer:
City Lic. #:Z 5,5", ,
Address:
City. ST. Zip:
Telephone:
State Lic. #:
Name of Contact Person: x Alo z,-ti-S�4-ue<S
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: 3 r&, r Stories: # Units:
Telephone = of Contact Person: 7 7 / " i r
Estimated Value orProicct:t
APPLICANT: DO NOT WRITE BELOW THIS LINE
of
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
2
Plan Sets
Z
Plan Check submitted /
Item
Amount
Structural Calcs.
Reviewed. ready for corrections %/��p
Plan Check Deposit
Truss Calcs.
Z
Called Contact Person a�%��
Plan Check Balance
Title 24 Calcs.
Plans picked up �ji
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
:•' Review, ready for corrections Aw /I !14 'L
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
H.O.A. Approval
Plans resubmitted
Gradin_ g
IN HOUSE:-
''' Review. ready for correctionstissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Sq/0
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Permit Fees
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WN-SHIP
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_WNSHIP. LINE_ - _ —
I' R+M/-
FD 1 1/2" BRASS CAP FLUSH N 89`51'34"W 2645.35'
1 1 2" BRASS CAP FLUSH STAMPED "RCE •
'AMPED "RC I 33441 PER MB /2645.37
E 33441 PER MB 285/17-21 /
15/17L21 ACCEPTED. AS S 1/4 ��
SEC 32 ORCHARD LANE
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