0312-021 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Divisi6w3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class - Exp. Date
763181 �. ' � �1.31A"
.Date ,f-- 12 -x Signature of Contractor
OWNER -BUILDER DECLARATION
.;'1 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.
()\)' 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 aT c'I I�iTsIi Policy No. I26is•4!
D
(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: f - FiApplicant
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 peisUq�
r -a
whose request and for whose benefit work is performed under or purs �a' to
any permit issued as a result of this applicaton agrees to, & shall, ind' r!21 'fy
& hold harmless the City of La Quinta, its officers, agents and empl e(s.
2. Any permit issued as a result of this application becomes null and v1,l If' J
work is not commenced within 180 days from date of issuance o su h
permit, or cessation of work for 180 days will subject permit to cance lati CI
I certify that I have read this application and state that the.above"inform tion is
correct. I agree to comply with all City, and State laws relating to the bul Ing
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ��/�'y Date
BUILDING PERMIT PERMIT#
DATE VALUATION T e*160 LOT TRACT
.r
JOB SITE
ADDRESS �?vC�- '� i BELiJUM19
APN
'7 7S. 35U ON
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Cl7?rl'LA. QtWf A 70, LP
31�f?riiAB aC�t; RE--30:Wr CC7NC&WErS, INC.
200.X WAMM40 OH AVE, MT. 100
2()4.1,rMI-M-1-aroI4k. , o wo
MOADT'no CA 92025
Ir SWONDi 100 q,.k 92025
(7e0)839-82:8 M4 541
USE OF PERMIT
A�gTaL rk' ay ,'D mnimt,,
`Sfrf) • :f..t i"1 .R, PL&W ZA. PERMIT 01.7FS NOT ;! YlCLLfCIF'SWICK'11rAl,I.A.
POOLi 41PA say .tDRJ-V WAvr.A.€►PVtOACiI, :151A,1i,EDUCTIOR TO PWI raiz
rB'9 DUE TO $tiUll OSPJA I�SUKNCE OF SAME PT.AN TYPE, '
COSTOM COWTl- UCTION %488:00 OF
;int. RC:RfMATIO 749.630 SF
C1.AI:.4's'a4FMA,lilf'ORT 660,.00 8F
EIVIKATED CONT OF C0N;r! 1t`C11 T0,K
12,94111M 1 .W
CONSTRUCTION Fr%1 101.000.41£3.000 $1.,322,09
PLAN CJiW:t VZZ 101-000-499-318 $269,612
MECHA141CA1. ME 101-000-421-000 5143,50
;Z1,E.�; TP, ICAL. 0 UE 1Ct�-t1Cl�l-�t?f1-IiGCt °��lt?.:JB
PLUMBING 101.000-419.000
::'FRONT MOTION ORE • f,Z3ID 101-000-241-000
CRAM() () CEls 101-000-423-000 3.000 $19, 150.
DEV :0MPACT RZ p,405.00
ART N PUBLIC PLACESS - Ick,.SIt 270-0Qt'1w145'- 00tt
d;. . TOM WWI AID CrIONA PIAN 0-'IF..C;I:£.
$4,810,61
LI
AN 0 9 2004 : mir. N . w
.,
TY[ Tt.A QUINTTA
UEP
RECEIPT
DATE
BY
JDATENAJtD
INSPECTOR
i
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 Zo
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing a
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int Lath
u
Final
Final
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 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:
fill
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)