0203-427 (RER)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Se ' ction 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
71091 0 08/31/210
Date Old", ;X 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:
( ) 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).
( ) 1, 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.
( ) 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:,
Canier k,7 1,
& MJV Policy No. K=*01.266
(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
P-bde, I sh�ll f 1hwith comply with, ptp e p I Ons.
Date: Applicant—.,4
War6ing: Failure to secure Workers' Compensation coverage is unlawful and
shall subject.an ei;'ployer�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 app!,icaton agrees to, & shall, indemnify
& hold harmless the.City of La Quinta , s officers, agents and employees.
2. Any permit issued as.a, result of this application becomes null and void if
work is not com.menc4d; . �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'�bove-mentionecl property for inspection purposes.
Signature (Owner/Aaent) Date
PERMIT#
BUILDING PERMIT
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 7"I'1111fGHWAY111
APN
.
OWNER
CONTRACTOR DESIGNER EN61NEER
-SMON FANULY TWST
PRCK-Murovii 111F.LAYX)M Me
71;411 HIGHWAY III
X0'aX-X 1406
Ui QUINTA, CA 'M53
ITIMEMLA -CA 0593
(MA", 4-4114 CEIR, 2313
USE OF PERMIT
I
J1VRRC.M.WJWU8
INNTAILATKW Oke MW 2ND BTS FWPfAftXf CAWMT ON RMSTiNG
VALUADON M
FPS IMK)Srr 41.00.00
KAN COROK, PT -B 101-OW09-318 $105130
CO�AST-RUCTTYKIW IqM 101 -0604).? -OW 1 $162.00
to 1-000.430-W-11 I MOO
APR 2 5
C(TYOF I*A
N
&UH-TOTM, CONNTRMMON AND PLAN CHECK
1.9,88 PRE -PAID FEES
4100.60
TOTAL k*,RN1X1'VF= =31, NOW
RECEIPT
DATE
6'y
DATE FINALED
NSPECTOR
4�
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 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
COMMENTS:
13L 0 v`G d G� ,S i'� 6 2_ --AZ
J
-
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
R(x)gh Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
0,.�
OF T
To: Greg Butler, Building & Safety Manager
From: 44*•t4,Y4<r , Planning
To CDD: 517710 2
Due date: � S�
sy
Status: 11--6"W64
Building Plans Approval
(this is NOT an approval to issue a Building Permit)
The Community Development Department has reviewed the Building Plans -for
the following project:
Description: 7-� W PM44;7- Cl�31N�l ��c�� pn/ �X%J? AAG /T
Address or general location: 76- 611 - --.R(-JY ILI
APN and/or legal description: S I /'-) onl M o7on-5 03 - o Z�D- o o r
The Community Development Department finds that:
❑ ...these Building Plans do not require Community Development
Department approval.
19- ..these Building Plans are approved by the Community Development
Department.
❑ ...these Building Plans require corrections. Please forward a copy of the
attached corrections to the applicant. When the corrections are made
please return them to the Community Development Department for
review.
� y1 -
Planning
Y,
/CZ -
Date
YOUNG ENGINEERING SERVICES
Letter of Transmittal
To: ��' � C�„�._. Date:
�.:�_
Project:
Attn: W. 0.:
Tel No.: Tract No.:
We are forwarding:
No. of Copies
1
4g/ /0, �- -
sr Gylc
By Messenger By Mail Your Pickup
Description:
S'1T�ii G�� 1�►7 Gft/ GS
Comments: P1 y15 4g5-
This Material Sent for:
Your Files Per Your Request
Your Review Approval
X Checking At the request of.
Other
By: Marcell McElroy
Phone # 342-9214
47-159 Youngs Lane • Indio, CA 92201 (760) 342-9214
dBronz Young •
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