0104-074 (RR)t`-..•••'...wih AY. �'`.�"':'T°.^.':;`;�.��_..^^,:Y*..-.4^•''�Xr�,=,��.•�i�.,.,...a,!•aby�rt�:•.w.-•.+fYr'tYr�w...:iY..�i^f�.lR�?'�,..+�•ii+TMN!�r.f^b�•wrvrn`_'WMFG#iwW�fr.wY.41:�:.miA'si.q.ri,:u,s.`wi.FiMT7+'.•tis.i:iii lldldo.+�l",:F^,..•--'...r��:.:"
vt_'{'4LICENSED CONTRACTOR DECLARATION •r+`}��H;
W I her 'rm under-enalt •of er'ur'that I am licensed'under rowsions of
�_ eby_affl ..-.. _ 'P Y P 1 Y• .., P. -,.
;,Chapter 9 (commencing with Sectio6t7000) of,Divislon 3 of,the Business and '
Professionals d66; and?my License is in full force and effect:::
Llcense # Lic. Class Exp. Date
t
Date =Signature of Contractor
''. OWNER -BUILDER DECLARATION'
�I hereby affirm under penalty of perjury'thatI am exempt from the Contractor's
t 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 isnot intended or offered for
,sale (Sec 7044, Business & Professionals Code).
as owner of,the;property,,am exclusively contracting -with licensed
contractors -to construct -the' project (Sec. 7044, Business & Professionals
Code)".
yi -, -
I exempt under Sectlon B&P.C, ft i this reason's
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.
(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 b
subject to the workers' compensation provisions of Section 3700 of the
Code, I shall: forthwith comply with ose provisions.
pate 1� Applicant^
ers' ompensation coverage is unlawf I nd
Warning: Failure to secure Wor(
shall subject an employer to criminal penalties and civil fines up to $100,0 in
addition to the cost of compensation, damages as provided for in Section 706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and S fety
for a permit subject to the conditions and restrictions set forth o
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 informatiori.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 ihspectionpurposes.
1 ' ignature (Owner/Agent) -/r Date
IT
njr r cfi}i c`C �" i y�'? EMvt4fV..PERMk
-BUILDING�PERMIT Y.. > .� . L
•'d♦ , 1 - - a._i...:-7+ : ri;�f 'r.lr r -r 'fit ` =,x,....1..1 l;hAYS�' Pt.".. •�, i
'0
fF`N,
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DATE rb, VALUATION .�, •+ LOT, �� 4 4 ,TRACT. ;
)• 16A7'FO � QK.l6b' 7tt. r i '� IA'1�7!i: �� •'I iri. LY.l�ip'i.�•t�: vi i'•tS
JOB SITE
ADDRESS
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r
r\ ' �, '}'�10Eta 2
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' •`a•N'•c."�J.,;+111.VIL..Lrw7/l�CO.i4,�rf,5.:7,t!.oG,^
w• •.�•h,
OWNER a
CONTRACTOR/ DESIGNER/ EN (NEER 5r -.414
14 •• •� '",
al
ji
OWNER
.a.:4.63 (+.1� J�i€� �'
- -BUILT Z J ,�,
�..�i,fx.1�6 CIN
.
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� � � 7 1 . 'X eEt+A �A ♦..•7.111i�F ���A'
USE OF PERMIT
MOMtypo- v�.ry��+ p y r��,/ Yyeq{,�y�{ a 99.L 1.v , .�•S e e cf• R2, rf � 1 � f�•l tl •' 1 # ��J
il7:.0\6ii✓6• 96411.'2 Me4YLviPOM 10FY Wl�AAiV W�.:ES (C l�.r�S,A .['D 6 dkt.7i l\.['!A[ eN i e&
p�li�t� `�f• �'',
♦' .".
VALUATION 61
.
y
NOTI�. iiowr OFC:�iiV49`3:,m'F:JC"'I<`E��d
3. .00
RFA100FFSE 107-000.4:8-000 SMODi�it
�ikto,t+o f`
APR 10 2001
CITY OF LA OUINTA
FINANCE DEPT
/CWWp
;•Y4 rp�a'=/`��/•"ys/"1��'`r
(..:t
90&TOTAL<!Jpy S Ri20JMIyV CA4
TOTAL MOW ms D n., 14 ow,
'i
t
01
9
pS a
RECEIPT
DATE
BY ; I
DATE FINALED
INSPECTOR",raj
rG�
O-�_
«.• r,t �F•�x�� rYf�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
F(-,ims & Footings
Ducts
So Grade
Return Air
S ?el
Combustion Air
RW 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
BLOCKWALL APPROVALS
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
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
I Appliances
Final
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)
COMMENTS:
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