0108-190 (SFD)if LICENSED CONTRACTOR DECLARATION .
I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
w•'• • Professionals Code, and my License is in full force and effect.
p =) C) License # Lic. Class Exp. Date
1--0L
} ti � 76;,31X37
i. o�Z r�_ Date Signature of Contractor /V In 1� F�.�.•^
U (DQYMM-II%UILD.EB.MCL AFiAZION .... .'
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
1 -License Law for,the following reason:
Z_ (.) 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 lir..ensed
contractors to construct the project (Sec. 7044, Business• & Professionals
Code). ,
Cl) O I am exempt under Section--, B&P.C. for this reason
U1
N Date Signature of Owner
0
N
d Q WORKER'S COMPENSATION DECLARATION /
C) Q 'Z. I hereby affirm under penalty of perjury one of the following declarations:
H p.. () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LLcompensation, as provided for by Section 3700 of the Labor Code, for the
.`� Q performance of the work for which this permit is issued.
Q (> ( I have and will maintain workers' compensation insurance, as required by
O U. Q S2'ction 3700 of the Labor Code, for the performance of the work for which this
L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier Policy No.
Ob Z—)
ZBiN1`Sir11111;1. M ;r*1'+8234.506
J (This section need not be.completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
3 subject to the workers' compensation provisions of Sectio 3700 of the Labor
1 Code, I shall forthwith comply with thos pro, sioIS.le ��
F Date: �4Y,61wr Applicant_ t-42 a: &n f•$`
-^'Warning: Failure to s&cure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of•tle Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director.of BLilding and Safety
for a- permit subject to the conditions and restrictions E.set!forth on his
application. /
1: Each person upon whose behalf this application is rade & each person -at% -1
"le
'uant to
whose request and for whose benefit work is performed under or
any permit issued as a result of this applicaton agrees.to, &sha' ni�Y 1
& hold harmless the City of La Quinta, its officers, agents a,"dlooy&X 12. Any permit issued as a result of this applicationbecomes duvoid if
work is not commenced within 180 days from date of issance cfy06011F
permit, or cessation of work for 180 days will subject permit 1bcancel _1affi6^n1AN1
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspectio�ntpurposes.
Signature (Owner/Agent) lZ/1 " E�.� a Date
-BUILDING PERMIT PERMIT#
DATE VALUATIONLOT Qln-1 Y TRACT
i, jt2i4 9 (rio 71.4 A 28961
JOB SITE �,�,,.-•-
ADDRESS
AP N
;134 ,�:�.�TORTZ0 , f
77-5-'�•i►6'&• 19
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CIRV, 1A M. P
/Z:00 IAV W r:E-3.RAFr N AVENUE V fE 100
7,Od3'F.;, Vv'AMEINUTON AVZ 0100
RWORD100 CA 312029
MCOATDWO CA 92025
C160)839-823..8 CrRLO 5413
USE OF PERMIT
MPJ.LE VAMILY Di7 F Xyl IG
W1+'.t�nPLAN 2D uA1AVUS OFAMP MIT 00M NOT INC1,ling El'aCK ` ALii.,
POOL OR DRIVEWAVAPPROACH
CUSTOM CONSTRU MON M83.00 37
POPIC1'0P IO 748.00 SP
G12..ieGMAltk°ORT 60.00 SP
i
FF1 DEPOSIT 101.000.439.31 f$ •SI.00 ,09
P.ONSTD.UCTION ".9 101 -00o -41a-600 $1,322.00
PLAN CHECK FEk? 101.000.439.318 31,076;74
Pp@C9f,1`tA:3'LE.AL,, ift: 0.01-00042.1-000 $122130
TIACTRW.AL FF% 101-000-420-000 $193.28
kf1.UARDINO'FES 1101 -DW -419-000 $202.23
'wRTRONa MOTION MY, 11UID 101-0004AI.000 $20.46
OR-WfRC FEE 101-000-423.000 $20.0101
DEVlai,CP.ER t6IPACT FV1E $1,907,00
IM :rr'1.BB111f, VLAICIlro • RE51r,?01-000-255-000
Ulk,-,:T`OT .Ct31F�1°E:L�".1•i�i�.#IO �'>,$�rfPL�r':'1C�F�,f�C
55,911.73
6 2001 TIMI fir 4 •FAM IT"
414000,00
DE!_T
`1
RECEIPT
DATE
BY
DATGMi ED
INSPE�TOfi
►A�
INSPECTION RECORD
- OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
6
Ail—
Underground Ducts
Ducts
Retum Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
Framing
Insulation
_ 7 (jZ�,,�
�� 02
11?�
Exhaust Fans
F.A.U.
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
3 y+!/oZ �. u
Final
Final
15z�of (!�
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 AP ROVALS
Waste Lines ��-/3�� 6
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection%��
6
Encapsulation
Gas PipingGas
st
ces � /z �
Appliances
� � '�p�–•�`KJ
�l
Final
COMMENTS: /
�`a,9l�tj /Z�S�! 6�✓
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)