0211-022 (RPL)LICENSED CONTRACTOR DECLARA`A N
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
to 146 11 £:53 (73131J`A(
Dat err Signature of Contractors t
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, aslowner 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
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
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:
Cartier 3•tA T ,1OI, OD Policy No. 0461040-M2
(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, I shall forthwith comply with those provisions.
Date: A / ApplicaJt? <+
/. 7!, / u 1 -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT, Application is hereby made to the Director of Building and Safety
for a permitdsubject to the conditions and restrictions set forth on his
application. °
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, ind
& hold harmless the City of La Quinta, its officers, agents and emp10
2. Any permit issued as a result of this application becomes null and
work is not commenced within 180 days from date of issuance ofIii
permit, or cessation of work for 180 days will subject permit to cancel
I certify that I have read this application and state that the above informacorrect. I agree to comply with all City, and State laws relating to the b
construction, and hereby authorize representatives of this City to enter
the above-mentioned property for inspection purposes.
_
,.'-
Signature (Owner/Agent)0;1y� Dated'T/"fx
BUILDING PERMIT PERMITk
V
0211 -Wil
DATE „ VALUATION LOT TRACT
LJOB
SITE
ADDRESS 81-115 S��'f'�a'.LI'Ttf,,: T) VRAI�,�-f�� E
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER
DIMIGN0FDRHORrox
;1'10,.13OX-1.137(91
C.A. 92606
LA Q1iWiA CA 92253
i';E3.;# 1945
USE OF PERMIT
3!0GI.• .fND/CyR ff;�a
ax
•
POM, & SPA ONLY. At.,£t 043.40ARWERS SHALL i#.F, M FL.64-CF. PRIOR TO
1yR1?I'NlASTM NOWT'1'ON, P001, P_,QU1P1jf1?)4T NC°1..63SURF, NOT Rit"i,UDED
114 PF,Ii.€yf1T,
t' OOL.&N$"•JOR;~3I A I
EST".*TED CONT OF C!PX9rRU(_M0fl`
PLAN CHECK FEK 101••€3i,-43'�a318 31FS,".
Ct7R411PIUCTION EIRE 101-000-4)9- 000 $16 .00
MLCHANIOAI, Mr. -- P001, 101-000-421-000 sm, M
7'I..Nta". RI CAL YEP, . PO0L 101 -000 -420 -ODD V15.011
PL1MIM0 Wt •- POOL 101-000-419-000 52"1.ri®
f
8-
__EM_-T,0TAL CG7l.�SI'��T1'u*. ON AND P1:,AN' C CTX
p At Y- IMT Fes: ME Now
NOV.+�
p 2002 L}
(FOF LA QUINTA
INANCE DEPT.
t
RECEIPT
DATiE
BY
°DAT FI ALED
INSPEC O
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground PIN. 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
d �
Final ',i--���/j
CO^MMS ANTS:
Final
!♦Ibd 000(((JJJ
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)
i.
0
?o PER. 103 LIN. FT.
S.A. 504 50. FT.
ii rr
lSPA 11 X 1'
. MIAO �4q
SO. FT.
flECoIC 1650 SQ.FT.
lXao fx ;
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