RER (0310-163)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
699640
Date
to '"N -7 � 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 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
CL Z WORKER'S COMPENSATION DECLARATION
o 2 1 hereby affirm under penalty ofrperjury one of the following declarations:
r FQ- O () 1 have and will maintain acertificate of consent to self -insure for workers'
X w �= compensation, as provided for -by Section 3700 of the Labor Code, for the
m�� Q performance of the work for which this permit is issued.
Q U ()' I have and will maintain workers' compensation insurance, as required by
O U QSection 3700 of the Labor Code, for the performance of the work for which this
LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier STATE R31 D . Policy No. 1 4t185d-2083
co 0
r p s
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(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 provisions.,
.,Date•. •+ ' 1 670'.iApplicant
• Warning: Failure to secure Worker Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes j
/,,Sronature (Owner/Agent) .'Date
BUILDING PERMIT PERMIT#
0310-16.3
DATE VALUATION LOT TRACT
cz/<T /1 - ,4 ' 3448
JOB SITE
ADDRESS : oe a � ,YEMJ)dj .L�i Fo%�� iC�
APN
OWNER
CONTRACTOR L -DESIGNER / EN (NEER
III OMA 9 F& .B:Y IXE� AI;1Zi'uTARF
1). V1. JOHN3,C014 cCs1W'm"mw, IRC
49-963 AS AON:CE..�2.0
1445 SUI�'.�5.: 07AY ; SUTTE 203
:L,A. QT.T12+ TA' C k 92233
PAL -144 3MMS C;A, 92262
J
(760)416.1144 ML01 5525
USE OF PERMIT)
PF.81D®I�,41`7UAT RMODEL
t
232 SO,.F1`..DZC:Tf ,F'.D'DITION ON 214D PLPL• %Vp1ercerdW h) p&—va:4
0204• i 28,().5:15 %q.-& Dd .fir adtiNt+ N 6203-343, 2001
CODES. 18 1f2 X I 1 P A14S AND STRUC T'UPkL. CALLS.)
DECK ' 22:2.00 9F
PERMIT 4i'1�t' NIUM !$ARA
PwiCHECI. FRE? 101.600.439-371'5 $140.00
CGOSTRUCT1D?d FEE 101-000-418-0 00 $54.00
FUCTIUC.AL FEE 101.000.42.0=000 $1'g.00
PLUTAH1170 E+RE 341-000-419-000 MOO
STRO140 MOTION FFR - RESID 101-00044.1-000 5.50
ra
FEB 2 6 2004 n
CITY OF LA OUSNTA t
FINANCE DEPT. r�
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T MAL PTEnISE If IMS DUE ii 01V
t 12-3 6, 15 0
RECEIPT
DATE
BY
DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
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
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
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)
COMMENTS:
CC {,,.c C, -
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City of La Quinta
Building a Safety Division
P.O. Box 1504, 78-495 Calle Tampico -
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
310 �63
O
Project Address: ✓(� /L-�p
Owner's Name:
A. P. Number:
Address:
Legal Description: _
City. ST. Zip:
Contractor: (iti t C%od��`fJ r�� �T'
FTelephone:
Address: t/ ( l orstpg �,��..yl, 5 (,� �'
Project Description: o ��
City, ST, Zip: A (65 6—.4- '5';)o-6
Telephone:
State Lic. # :
City Lic. #:
Arch., Engr., Designer:
Address:
Cite, ST, Zip:
Telephone:
P
Y
Construction Type: Occupancy:
panty:
State Lic. #:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: �-O s.p��
q. Ft.:
Pstimated
# Stories:
# Units:
Telephone # of Contact Person: o — 7S- J v
Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING29
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
pZ
Structural Coles.
Reviewed, ready for corrections
h
No Check Deposit
Truss Coles.
Called Contact Person
f `
Plan Check Balance
Energy Colts.
Plans picked up
�/ 6
Construction .
Flood plain plan
Plans resubmitted
p1echanic21
Grading plan
2" Review, ready for correction issue
�
Electrical
Subcontactor List
Called Contact Person
ij /O
Plumbing .
Grant Deedtl
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Review, readv for correctio Issue
2 (�
Developer Impact Fee
Planning Approval
Called Contact Person
A.I,P.P.
Pub. Wks. Appr
Date of permit issue
�-
School Fees
r
L
/ ��
Total P F
ermrt Fees
I°�3'0 /1a-GAP�jlof. c /• F S r .44/4. ��5 a l a
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