SFD (0104-261)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 r✓°Ezp. Date
4 7603:5, �� .+rte ���_ cif � �,.•'
Date .,. �-�" Signature of Contrac
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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
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.Labgr Code, for the
perfonance of the work for,which this permit is issued ?
04, 1 have and will maintain workers' compensation Insurance as required by
Seotlon 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 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 soy>ta-become subject to the
workers' compensation laws of California, an gree that if I should become
subject to the workers' compensation prov ons of Section 370016f-the'Li r
Code, I shall forthwith comply th thos.oyisions.
Date:` Applicants &-"-�
I .,Warning: Failure to secure Workers' Compensation coverage Is unlawful arid
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety .
for a. permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this. application is made & each person at
whose request and for whose=benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance, of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State,laws relating to the building
construction, and hereby autl orize-represen'fatives of this City to enter upon
the above-mentionedpr p ." for ills purposes
SI'gnature (Owner/A , nt��"
..�`7.3,r
BUILDING PERMIT PERMIT#
DATE VALUATION LOT r� -y / f TRACT
2,9147-2
JOB SITE _
'ADDRESS <- y
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
ASHB ZCJM D V ELOPMEW CO1ti PAITY
ASMAROisKMI 'I' OPAGNIT s ~OWANY
51.40 AVW, DA EIIvOXAS
3'.1 HE'D AV1. NWA.T 'A229
0:1MPIA D CA 92009
CART.J4 A1.) CA M 08
(760)8UW6868 CB1df 3376
-
USE OF PERMIT
i.
MM? TAMIL 3".J`l MA a.4G
IST'. - IMMI,if;I,. I PLAN I LOT 22 - PR.�il IT a..lORI:1140 i` INCLUDE Bf.rf;, X
W.+31:3PD203.d PA OR API'1T$O.fl.(IT"fl 1')&t.P'1'EiRFAY.,
CUS'FON CONSTRUCTION 2,5131,00 9
PDiIr}IIti�iJ.f}ft sF
0ARAGEWARPORT (BY) -I
E, DT?P0RJ T 101-000-4139-318 _000.00
CQNSMUCTIOU R12 10'#."M*21-418 EtrT(? T6i.. r0
41,.,f N CHECK FIRK.9 101-000-11.39-318 770.99
Mt.HAIsTICA1. IAF: : CY9 ��1�10�I21-41t`,U 37'�.titt
FIbKTMAL FEE 101-000-420.000 $121.30
PLUM,W.141111 FUS', 101 _000_4 S1 69.715
0.10 I.cONCI MOTION M,, R9910 1.131 o 000.24,1„4VO
10)-00(1-4T;3� 000 814:�te
VRILICU0a1.V 131ND PLAR 1..rf.L4�n�ita.
.. $4,051.0
LFSH PFZPA6 M0
4500.00
APR 2 4 2001
AL FEIMIT FENS DUR NOW
S3,557.67.
CITY OF LA OUINTA
FINANCE DEPT
RECEIPT
DATE ,
BY
A. c
DAUF ALED
INSP C OR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
_
�3! a�
Return Air
Steel
. Roof Deck
_ _Combustion
�'p// D/
Air
Exhaust Fans
O.K. to Wrap ��
F.A.U.
Framing
Insulation
_ _
$� _�/ _
_ (p�
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior LathS/
D� wall - Int. Lath
Final
_
I
�lj_
��
_
5��/
Final.
POOLS - SPAS
BLOCKWALL
APPROVALS
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
� A
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
!f'/9/6 �/�
Pool Cover
Encapsulation
Gas Piping
_
Gas Test
Appliances
Final
COMMENTS:
Finale/�
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)