SFD (0301-025)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 # M a9Lic.Class Exp. Date
111131 1103
Date.'., ` ' Signature of Contractor t
OWNER -BUILDER DECLARATION
I hereby,dffirm under penalty of perjury that I am exempt from the Contractor's
License: Law for the following reason:
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).
J. )' 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 t, 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.
r(, ) 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 IrATR FUND Policy No.
(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 provisions of Section,3700 of the Labor
Code, l shall forthwith comply with those p ovisions.-
Date: LrM w:, Applicant
Warning. Failure to secure Workers' Compensation coverage.is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application Is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth"on his
application.. `
1. Each person upon whose behalf this application Is made & each person at
whose request and for whose benefit work is performed under or pursue
any permit Issued as a result of this applicaton agrees to, & shall, IndeFc
& hold harmless the City of La Qulnta, Its officers, agents and emplo
2: Any permit Issued as a result of this application becomes null and v
work Is not commenced within 180 days from date of Issuance of
permit, or cessation of work for 180 days will subject permit to cancelli tlon
I certify that I have read this appllcatlon and state that the above Informatl n is
correct. I agree to comply with all City, and State laws relatind to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for Inspection'purposes.
Signature (Owner/Agent).
-y Date
I i/AtS a.,.
1
BUILDING PERMIT PERMIT# IN
(MI -M-05
DATE VALUATION *22DARM LOT C; TRACT 294573
JOB SITE ADDRESS �` � �a iA , I IV �
APN 649-10&4211.4
OWNER
CONTRACTOR / DESIGNER / EN (NEER
l,13:1"3EMU'`
9PAR:Wdr O3'391RUMUM
PO BQX ) 7 t
1„{1311+tYaCA :45
T fQlii`ai CA 92753
299.
USE OF PERMIT
r
SPI. •- L,0T 4NLA?d UY. 6"1:;A441T T)0ZS' 1%T0T 1'tJCL;UDZ 3.t..t; VK'i`VA..T LS,
POOL" 3PA 60, Z'eRIVEWRx§" APPit+?AC•li, 13% PLAN CRM.CK FRE y
'E:.i?'1.�1_t0'tTdGt•3 .F'C�'tc;+�/3sJi.'i'IPiL,Ir::.�.;iil�'�t�YClr ltil� e�s.pKL 1'1 11�'ht '�"i'3�� `'
CIJ�`f'ty�i2 �03�w"!'FtftJ�'1'iQ�d - 2�ES'sS.'�t�
P'D'RCWP. A.TIO 267.00 ;;IF
04aF4.: flk ICA9PORT 614.00 `x.P
Es'rl"n- ID CONT CW c(M.'rRI TCT1111:
2'?$ 99,2.00
CONS TRL1tr`10.4MR 10.1.000-4184M $1,063m
RE,AW CHECK Fs0f 101.000-4.3:9.318 S21' ,40
MIM041CAL FEE, 101-000-421-000 SIOS.00
1?LECTRK'.A1. FEE 101<-000-M-060 $176101
PLUMBING YU 101-000-41M',000 S1'MS
STRGHO 101-000-241-00 a:t?
t)(a`!-sDD10 K11N 1014;00 423. j'o It'll - 00
DXV 91.0VER 1*JlPA T FZZ $2,405.00
E MISS FIRE 1�0 f1I 1040�U,
OEi
JAN 2 2X003 i TOTAY, PMS F , DIVIF arc
,+.
!TY OF LA QUINTA
FINANCE DEPT.
RECEIPT`
DATEBY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
/% —
Ducts
_
Z-
Slab Grade
_ 2-,,'Y—
Return Air
Steelp
,
Combustion Air
Roof Deck
Exhaust Fans
_
0. K. to Wrap
_ ., j
F.A.U.
Framing
y _ �., +•
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
��B —J
Final
POOLS -SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
-
Heater Final
Water Piping
Plumbing Top Out
�/�
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Z .�� _� f
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) ✓5
=5
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) s: