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
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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,
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W,A11L
EXHIBIT D
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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)
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`^E EXHIBIT E
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EXHIBIT F
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0 -I QFLA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE BY
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