0402-099 (MECH)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. Classp� Ex . Date
29905 1 B
'Date t�utO '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:
MI.,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 STATE MD - Policy No. 040-100013
(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 manAer so as to Become subject to the
workers' compensation laws of CaliforniaL,6d agr a at if I should become
subject to the workers' compensation provisions o S ction 3700 of the Labor
Code I.srall fo with comply with those r/(ovisio r .
tDate: "J k/f Applicant
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 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 hand State la s relating to the building
construction, and hereby authorize representati�6s of this City to enter upon
theabove-mentioned property for inspection purpo s
iSealg' nature (Owner/Agent).. D3 Date
BUILDING PERMIT PERMIT#
DATE - VALUATION LOTS TRACT
�3t10.�Iaa
JOB SITE
ADDRESS r•.��%li(IEC.{WA Pi
\
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WASH -UN O OW TCI, :>;n)
C. M FRY CONSTRY:a'MON CO.13SfC
74-770 WHY 1).1 3TMEx 202
PO 80%,1769
DTDTAk i'' w -'s, tit
UA"'AD CA 91185
f'909).910.501 r C;3.TBD
t
USE OF PERMIT
MF,C)iANICAL SPI IT S YjT,F,M .P.DUI: cars AT VF TI,,.SUI, a...0? LTA 2
REV 1810H FOR T1 PERMI'r 0308-4431,
VALUATION to
OF CONTUCITUN
5,(Moo
PLAN CHECK FEE 101-000.43.9-33 8
C014STRUC s ION MEE 1,01-000-418-000 � � 0onoo
bASCHANI AL'FEE 101.000•-421.000 $391%
C 1t. 111MUC1,10H AM PLAN C:'fIFICK
LIE FJ0S
FEB 2 0 2004
*y �e�}ry�p t 6 � t,.���%�.:�p:���P��XM
CITY OF LA QUlNTA
F1EyAH.CE.nEPT.
RECEIPT
DAT`E //
BY
DATE FI LED
INSP TOR
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:
-
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Total Permit Fees
Bin #.
Q • of La
tY Quinta
2'
Building aL Safety Division
Permit #
P.O. Box 1504, 78-495 Calle Tampico
•,� �/
La Quinta, CA 92253 _ (760) 777-7012
Bull , FhOermit Application and Tracking Sheet
J�
Project Address: l WnZ )
Owner's Name:
A. P. Number:
Address: fl8`l�-
Leal Description:
City. ST, Zip: G l�t��llJJ
X
Contractor.
&f`( d
FTelep hone: ��-. ,
Address: J
XPr0jcct Description:
X
City, ST, Zip:
'
� � • ��
V
y ...- Wit,,. �.._ -
Telephone:2A
Lt
A `
A
1u1
-
State Lic. # : 2,N6 City Lic. #:
Arch., Engr., Designer.
Address:
City, ST, Zip:
Construction 9
Type: Occupan p
ty:
Telephone:
..
State Lic. #:
..^.`' .F� 1r -
Project type (circle one): New Add'n Alter Repair Demo
X
Name of Contact Person:
XSq. Ft : GJ JJe'10 # Stories:
ie
# Units:
Telephone # of Contact Person:`�� -
stitnated Value of Project: - mn
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'dTRACKING
PERMIT FEES
Plan Sets
/1 Plan Check submitted I/) Z
Item
Amount
Structural Calcs.
Reviewed. ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance i
9p
Energy Colts.
Df Plans picked up
Construction •
-77, qO
Flood plain plan
Plans resubmitted
Nicchanical •
*9•QV
Grading plan
Y' Review. ready for correcti s<ssu
9 o
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.Nt.I.
H.O.A. Approval
Plans resubmitted
IN HOUSE:-
'" Review, ready for correctio Mae ?iGact
Fee
Planning Approval
Called Contact Person
Kdig
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees