0311-070 (RC)LICENSED CONTRACTOR DECLARATION
�I h%eby 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 /
76,8595 ra CS
Date rt ! `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
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:
Carrier Policy No.
F� 1603616.02
(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 subj ct 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: f • ., 0 ,. ; Applicant -I
.. ,>i..
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civilifines 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.
,.Signature (Owner/Agent) {lj fF �) i'.%� Date
♦\) �'-� i.,, ' w .. � �
TN
BUILDING PERMIT PERMI0311-010
DATE 'VALUATION LOT TRACT
$lU�t�D:�d3 • •
jf at.� � ..:
JOB SITE '
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
ONE Mk;VEN LA QUNTP, LLC
DCD *DEV , JXC dba 13M Ui CTM48 DEV.
'3 3 *t3��•'���R9,�R.i� :i�NF?
' i 8«��►�y :EJTC}�:i'i�J.4Y 1 '1 '1
IA14CRO MTRAGE CA
IA QPTA CA. 92233
(7,60)771-3345 C'!k U. 21.80
USE OF PERMIT
N&C: U .Ai33.EOUS
)MfIItI HANDISING COUNTEM A. 4D ;?rXICN
2
VALUATION iii,@tltl.fl0,1�
Ew'TMATM MOI' OF OOa`1'X.[" .UCITOR
10,006 sx)
i P1,4N CHECK RX 101-000-4394318 b7ti3O�
CONSTRUCTION, FEE 101-000,418-000
�'OV 141003
CITSY Od~" L CiIbs
FIRIAN FDSPs g u
SUB. -TOTAL COMMMInTi'Lit If �l t P ?f; Alv" C 4"'
$193.05
TOTAL PERMT FEE8 DBTL:ROW
slsabs
RECEIPT
DATE
BY
�Zj
DATE FIN ED
IN P R4A
I.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final / / 3
POOLS - SPAS
BLOCKWALL APPROV LS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric '
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish •Plaster
Sewer Lateral
Pool Cover '
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
4
Bin CJ1 #
Permit #
Project Address: '78 ' l0 MY
A. P. Number:
City of La Quinta 6'-
Building 8 Safety Division
P.O. Box 1504, 78-495 Calle Tampico �►
La Quints, CA 92253 - (760) 777-7012 �1.0`671-
Building Permit Application and Tracking Sheet
llitOwner's Name:
XAddre« �� • �� '' - -=�-�
Legal Description:
Contractor: ` 3k� 15
Cirv. ST. Zi �2 3
Address:''zrllz,5 1E - SL 159Af-4r01JQ0 15jA./D •
Project Description:
City. ST, Zip: 5k- 56:f��
Telephone:(-ic,)5%'0�
State Lic. # : Q -&IV00(1- City Lic. #:
T' MAYdN pVe#6X-
Ll�'e o l W z;'o-ice l 5
Arch., Engr., Designer:
-7 4'7 P-
Address:
City. ST. Zip:
Telephone:
p=1
State Lic. #: Ce(( 3/0% 0' y1$
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: iot4.0
Sq. Ft.: -11 �
# Stories:
#Units:
Telephone # of Contact Person:b"Estimated
Value of Project: l4 ";Vo- es
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING PERMIT FEES
Plan Sets
Plan Check submitted
1/ em
Amount
Structural Calcs.
Reviewed, ready for corrections///
Plan Check Deposit
Truss Cales.
Called Contact Person
�j(p
////7 Plan Check Balance 10
Energy Cates.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review• ready for correc ' ns/issuc
"Electrical
Subcontactor List
Called Contact PersonPlumbing
Grant Deed
Plans picked up
SAM. �f
H.O.A. Approval
Plans resubmitted
Grading
Developer Impact Fee
A.1 P P
ll
-
Total Permi Fees
IN HOUSE:-
''' Review, ready for corrections/issue
Planning Approval
Called Contact Person
Pub. Wks. Appr
Date of permit issue
School Fees
f
J
,P