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0310-278 (RER)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 EXD.. I ate 14 Inc! 6tJoIG5111 Signature of OWNER-BUILDER'DECLARATIONJ 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. / NI 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`.t,'k';1.'�;ypY; Policy No. 2d�1.0(33,3�h6.2 (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 sWl fo •with comply wfth�those provisions. Date'/'S V" _ I APPlicant�.- /L, �� i .=L✓,l� :...�—! �✓ 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.•ipspection purposes. Signature (Own er/Agent),✓t;✓;�/t'"•?.••-- Date�� BUILDING PERMIT PERMIT# DATE VALUATION LOT' TRACT JOB SITE APN ADDRESS 70400 RAVMIR IVIt _ OWNER CONTRACTOR/DESIGNER/EN (NEER WLL&JAN' C4PYR1E BiB3iONiWJI:rIT i8rg9D..UA-�IRyL:NRZ 44-30-NAE3Qfj t ,,b LA QLTWTA. CA 9225:3 I3:113M- 1 Wll"KIS (11.11. 5'2210 (7,60Y/ 3-44,TY CrJX 6545 USE OF PERMIT 7'.VA, REMO :1 eJ . s '„ CiJff1r7l'+ ;^ d -k,00 M 11"I Tm I a::,of<.l7a�IM il+3'!'.r9.i, L. moC#•1 17tams A.T ' �FU1 VALUATION ION Jg4VW.W U', r', -11mTZ T1t coir Or CONG5�Ri1'CUON PEW&W:Fism 9.��°{ NIA,RV 11LAN CH-Hr'Y. "KE MAO COh1S7°RUC;'CIGH FEE 101-000-4 5 8_001) V2.00 ELEC 'i'iUOfilo F E1: 101.000 -420 -fly?`) a2410 Srt OINK] he0T1aV? FI;, , R.;= 3(31 -OG S-241.000) 5 e O � OCT 2 8 2003 CITY OF LA QUINTA FINANCEDEPT. OUBt•TOT�_. e�z� tre: 1 ala �>5,1�.� r�: r c :c�+ ; $141SO LESS ME -PAT) VMS 1011) RECEIPT - DATE BY EF I ED I ECTOR' it 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 BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground PIN. 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) X A X s Bin # City of La Quinta Building az Safety Division P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # 0310—J79 Project Address 0 jn2 Owner's Name: t �-a �� W >c_ 'k p A. P. Number: Address: —S Legal Description: City. ST. Zip: Contractor: Z; �Sd FTelephone: Address:rN % �;7 �r Project Description: City, ST, Zip: p t„, QA• "1� 3 Telephone: ��� 'I l 1`�:=•_'` Y.. �vl� J• �b\Ch `C State Lic. # 5 Arch., Engr., Designer: City Lic. #: Address: -2c , 3 GaD'a5 City, ST, Zip: Telephone: .. .. Construction Type: Occupancy: State Lic. #: Project type ( c1e one): New Add'n Alter Repair Demo Name of Conta erson: J Z ;y�� Sq. Ft.: ones: —F#Units: Telephone # o Contact Person: Q nj stimate Value of Project: , APPLICANT OT WRITE BELOW THIS LINE # Submittal Req'd Rec'd TRACKING PERMIT FEES Plan Sets 2 Plan Check submitted 101 Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance p Energy Calcs. Plans picked up Construction o Flood plain plan Plans resubmitted Mechanical Grading plan 2" Review, ready for corrections/issue Electrical di 12p— Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.I.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- '^' Review, ready for correction sue 10'ay Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue 10 Alu AM4 wp School Fees Total Permit Fees More: p4& .S7AN S'—" ;N Coy + f'• Ava-1 72z. jEND f-�u,.f %or— Cge/sr 'sot�'✓ 4'W A • 31,0 A, D � �wr%� of � ' r' �Pti /�-c /9&.f,/ Ivy# /to- /-� EXHIBIT B LcQ u , loxvA ,CA. X 5 3 CITY OFLA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION k v; r- • - �.::).hr^.2tlal.•�._'d :.y1%YttCC!01�X' �'c4/ mc ` OATE Q> gY � Brinson Devek pment Inc. FACE. CUSTOM HOMES AND RENOVATIONS WKS (760) 773-4487 KJERlD8pgWS0N CELLA (760) 409-3506 Fa)W (760) 779 0489 C, /0 a -W �): V) d''A)G W,A11L EXHIBIT D �3UJ MiJ�b y o= � «+ m amomw 1w nAwy r - CITY OF -LA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DATE �BY EXHIBIT C Dix CCt4ygM qR05 OUTLET W.iT . aUTLgT (Y2 NOT WT D) oAqMV4.T W1 BATMW BACK-UP. `^E EXHIBIT E DWp"x CONVOINNIca OUTLET OMIT OWTLET (1/2 HOT T I -W). dpMY.�as=T®TWw TVj . QST Wl DATligWr MACK -W -iQ TELZYMiON JCC EXHIBIT F Nc = S v �_ _ add rLit4 RAL - �h°1hA 0 -I QFLA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DATE BY X OunaT GMIT WOW !OUTIAt (1/2 WOT Sd6R C44jT l -• �- v {fes 7o wom� . � � 11"PHOW jAcK C W oc- it �i� 1Ukl rA To SLaA� WAX C2c)s s UoKv 1bMCL CQ b� S �c � (K) 30a, -4x)k W cc