0105-016 (SFD)LICENSED CONTRACTOR DECLARATION
Fhereby 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
' ' �i
Date �,��`" / //"'�� Signature of Contracto rik • 0/2,rye^-• ^�-^�^•-"'
���" ' Ofi117NE1P RIO 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 BRP.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 of4he work for which this permit is issued.
Q 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.' -
(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 not5'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
Code, I shall forthwith comply with those prQvisions
. /
Date :+ ✓ Applicant�� ,1... ;T/-�✓
WaWinga.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. t
IMPORTANT Application is hereby made to the Director of Building `and Safety
for a permit subject to the conditions and restrictions 'tset ''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, inde Iffy
& hold harmless the City of La Quinta, its officers, agents and empQees.p
2. Any permit issued as a result of this application becomes null andlvQuid if.
work is not commenced within 180 days from date of issuancejcf Such
permit, or cessation of work for 180 days will subject permit to canaellati n2'
I certify that'l have read this application and state that the above inforrfihation.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)?4_9_ 4 *" `"f _ :.g Date _/ '"a�
BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
I�
V
; 30 28961
JOB SITE APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN INEER
AVMNUE M.7 1,00 700 OR WAM:[ IT10.1 AVE. 6100
WSCORDMO CA 92029 ES C;C31tiEM0 CA 92025
.y p, (760)839-8238 Cry, 4 541:
USE OF PERMIT
S>ti'INPI,..1 N 1CntAM1,MS, 0F?1CF P9RN11T 0CY&3 [)T 11.9CLUDY, 8WICKWALY,
FOOL OR DRIVMAY APPROACH
CUSTOM CONVOTRUCT101.14 2 90,00 STI
C!t'tAR&ORUCARPORT• OF
1y r
AJ) d``O4,
CO'ha;3°t1=111014 FEXSOY
«t)1it9 a S i9 ii
$ ,l l�wZ.fik4
PLAN VIT- :CPQ 'r'iPMI
WXMIAPICAL FEE
$122,00
FAAW`a R.1GAI1 799
101400-420-00
$171Sfi
`i•LUtai6i2 INO 1?K
5185,24
n C F1.C11iC +1d� 1`19D)+! 1�7? a 1�.FS1F3
101.,000-241-000
$35.05
t fif11)1 RCg i,
101-000.423«000
820.011
3:M)ELirr;?°1''1'l ]UPACT I{t'r.;,�:
$1,907.00
,DIRT 1H PUBLIC PLACop r. W -Ir 701000.,2,55'-000
$126,16
1'i1:L DEPOSIT ti
r;
101-000-439.318
.s1;a'Yi10.0t1
t
2-50,463AO
I { AL� CO3�d '�'�3C:. ON AI�TggLSgqPL����,�'�%yD��ryS: CI -C y •,�S�. ��
.d.,4Y•.ti747 Y. �,II�ti Lii^PF�{.v' d�7iTW 41,000.00
I 1L62x1
"TOTAL 1v'-�:i��.aMI!'" "DUE �#CD�1~d ��t�+ �iSY
NANCr- VEA72.
RECEIPT DATE I BY DATE FI LED INSPECT
O
4 /2 os
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings _
Slab Grade
/d G
Ducts
ReturnAir
Steel _ _
Roof Deck /l p y
Combustion Air
Exhaust Fans
O.K. to Wrap)
_
r
F.A.U.
Framing
l�1 �- /(�
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lathy�—
Drywall - Int. Lath0
Final�'z/�
BLOCKWAI APPROVALS
Final
POOLS - SPAS
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
_
Waste Lines
Gas Test
Electric Final
Heater Heater Final
Water Piping
Plumbing Final
'Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral_
Pool Cover
Sewer Connection
�j�//
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
/
�-�j- /2/s/p/
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 (Per(n) �� ��
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
7 63 1 S-7 1 /2(
Date 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 37`00 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 7 Policy No. f
Z042394506
(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
Code, I shall forthwith comply with those provisions.
Date: 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, 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) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0105-0161 TRACT
"50,463,40 3111)
JOB SITE APN
ADDRESS qq L�s pp 77- 360-�1�T1
-J5:1-.d 5f) .fJiAif ; ijfi O Z1 �'+-
OWNER CONTRACTOR/ DESIGNER/ EN (NEER
CP,V L.A Q!.Jli'TCA 70Lf:i:iqi\T0V,%TrVE RESORT COI\D/fi7tT!' ES, s'TC_
200 EST WD.E-?L:IR: ON La M. S>i:.; 100 0 �' �� T.�i`T''?i J�i`1 AVE. 1 t'
e,SCONT;1T.)� : CA 92029 EoC'_,111=O Ct, r:11"20e25
(?F,Q')Ssy•5233 EL -9 5413
USE OF PERMIT
"' C
iv It`.'+,]ri LI:...:T Vr: :4 L., P.; r.:uu: DOVES INV 1 iii .1.JJ i.J e, BLOCK L. Ly
HQ j r-, j C` 1 N iV.Z'Vt: Y! a 1';-t
CIUi<ITr.'A,1 I.'01qkz;T Ui T1C iJ 2,91*14.00 iii
PCIRC1a;PA IO 53.130:,:
+01%.RAtti�tClAPIP III RT '674,00 ;"JF
++: -ITaitT iATE'D COST OF CO S'.VRI GTTOTv
00,N2i KU C'TI C.TY :.!.i'
10 JZ JI".4 1 -5"000
$}„f6uL
PLr.1'Y ....._C: F.- F FE.
10 e -0-00-4:5 9-_, ...
.9:561. L
11 H {I Y+ T} 1 j1 'i,, T'j
iJAr+_at.i� l..fl.L/ .IaL,
• n .'1�� q
i`i�0;0-42 00.j
ELECTRiC.A L 'FIEE
1 i? i -000-420-000
7177.96,
aJ (rN, ftl]i'Y LJ GYlV [!`�tFE'1 - f`-_rJ/Si
!(tt �iI,I-ci4 1 -IJv1�
2J.5
Yp Ii
1l♦./'i,i IN f.14E,4
7!-
rV{
i1,i1".:l/1,�uLf •.l ��a r'�T��
'p
f:i{T ?•A! PUBLIC FILAOLES- (1 s35i.1 701 ..,0-.255"r]0ri
'S,;GS:lii
F M Dy.7
-:Ir L:. '.J:JS t
f "010 , + 3 8
I J i - . lyt-tt y�-J : �.
"j!-'1.•J.�JIJ
i.•.1 PT .�tT (' 'CIE
zi..JL ._•Ji:♦f' J1V:J i vlY r'.L'J ). 1:!Li:' l-
I,E[
RECEIPT I DATE I BY I DATE FINALED
INSPECTOR
259,463,40
:;tr'6.-