0105-022 (BLCK)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 Si -A- ture.,of Contractor
R-BUILDER-bECLARATION
I here�y/affirm ur) er penalty of perjury that I am exempt from the'Contractor's
Licen a Law for the following reason:
( i) 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
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.
(A 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 Policy No.,
• �lI':?t»1�aI�3 kr,1�Y" o't:�;��13�. A�21�G�4
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the perfo„rrndnce of the work for which this permit is issued,
I shall not employ�anype'J`r� f in any manner so as to bocome subject to the
workers' cgmpen5`ation laws of California, and a %ee that if I should become
ubjeyti't r the`w�orkers' ompenSation provis{'p i"s f -Sec iU 3 00 of the Labor
' Co _el;-l-shallzio i eomply�t ] o`se provislgns.�i tJ
Dat t�" Appffcant ✓ rf'
Warn)*ng: Failu to secure Workers' Compensation coverage is unlawful and
shawsubject 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 18O 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 `Kerebyaiith•'orize"repr,�sentatives of this City to enter upon
,•-the above -me ti Heed roperty for inspection purposes.
Signature(0� "r✓Age ij="alk' - ��" Date'
BUILDING PERMIT PERMIT r'
DIT E VALUATION LOT �,�TRACT
OWU240C IM, 705 . ,
JOB SITE APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN (NEER
LA Qm3+au. C4A 92253 LA QIMFC€e CAI 9225
(160)7117-81V CSIA 6440
USE OF PERMIT
41 U. e V £t ' X1104 WA1111
CITY S°i°ANDAP 3
41.00 LP
.Pp� 66 pp`�♦♦gy�p� ����,,p��yy��pp yy t <(�q� W �K+pry(bg7�` p/+�p�
s��d,.�[i.�.tG.Nd 6+Sa'sroir co'NoA.A6,S�/Gpr.G4, N iW �P d1.•
PK amrr n. rt. SUMMARY
CONSTRUCTION R'X. '4;101.4010",18-000 S2.1.00
1r11
i
D.
fl
MAY - 2 2001
I( CITYOF"DUINTA I
( FINANCE DEPT
LZI V PIMNI,t W 14023 $0,00
`I'M &L PYNKI I P'E'ES DUE NOVO I - caoo
RECEIPT DATE IBY DATE FINAL5D INSPECTOR
INSPECTION RECORD
OPERATION
T 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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Footings
/
��[ g
Electric Bond
Main Drain
Bond Beam
_ 7
Approval to Cover
Equipment Location
Underground Electric
Final /�i/ O( ST
PLUMBING `APPROVALS
Underground Plbg. Test
Gas Piping
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
rMain Service
dub Panels
Exterior Receptacles
✓�.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
CITY OF I A.C)Hll\ITA
'. BUILDING & SAFETY DEPT.
APRT
FOR CONSTRUCTION
DATE
H11USE
• Q I 3
3 51371 AVENIDA NAVARR❑, LA QUINTA y
Z
F-
0 GATE
xI
LLJ
EXISTING TREE --------i
_ ( EXISTING TREE
i
n PROPOSED WALL n PROPOSED WALL \
�--6' �6
10.5' 10.5' 14' 12'
-- 3' -�
AVENIDA NAVARR❑