0312-026 (SFD)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Divisiom3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
76316 :B f31fri5
Date I ti -.,,i 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). 5
( ) 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 l
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.
(Af) 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 O'TATZIUND Policy No. 1€82031.0121
(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: ! -_ Applicants
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 0
any permit issued as a result of this applicaton agrees to, & shall, indemnify,
& hold harmless the City of La Quinta, its officers, agents and employee" .
2. Any permit issued as a result of this application becomes null and•uVl I if
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 cancel atioh--
I certify that I have read this application and state that the above informeytion is C
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
312-026
DATE VALUATION LOT 42 TRACT 28961
JOB SITE
ADDRESS .� .7 � �Cedi~�J Q"i.
APN 775.3MI-015-=
OWNER
CONTRACTOR/DESIGNER/EN (NEER
C:.% --V ,AQ(:T1MA'7(1, LP
I1140wi7'IVE Imaxw t'Cimi+J ul-Trims, Iwo -
200 Iw WWRi1+iG'Y'4JN AM Slam 100
2001 WASU NG- MI AM, 6100
r.SCONT-N.DJ CA 92025
ESCONDIDO CA 92025
ZtS41jF3 ^�23£i CBL# 5413
USE OF PERMIT
�4 GLEYAWLYDWEq y G
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SMO b LOT Qd, 'PLAW 3S. PI?titOT D093 NOT INCL i 10ELOCK 1JI'AJ.LS,
P0014 SPA,OR DR1117WAY APPROACH. "% RVID CTION' TO 1'TAN CHECK
'REF DUE TO MULTIPLE ISSUANCE OF SA1dY►.T. PLAN TYPE ,
CUSTOM C014STRUCTION ;904,941 VF
rii2tC iilt?A3`t0 814?,ti0 Sty
0ANg.611MARPC►! f 774°+.t#Fi OF
i'SS:.1iAA,TE d14:09JC 01+ ("+?�MM;2 CTICAlf .
329,496.60
CONSTRUCTION M, 101- X00-418.0 O $1,444,50
PLAN CHECK trill 1e1-000-4,39.318
M WHAWCAL FE4 101-000.4.21.000 W6150
ELFC a RiCAL FEE 101-040-420-000
PLU hi D IN 0 FT -E 101-000-419-000 $fit 2.rf�
STR0140 MOTION Y1n . RE,SIL) 101-000-241-000
ORADi`IG N"1`E $15.09
DMV ELOPER IMPACT FEE $2,4os. rio
ART Citi PUBLIC PLACES - i"ih-811 V10-000-446-000 $313.74
x - ; ULB O'TAL e,1 OMTRUMON AM PLAa1' cErim
$5,111.63
IY. S P'h'I PAID I=
=00
AN 0 9 2VO4 , I TOM
TY C! - : ,71, ' 1TA
RECEIPT
DATE
BY
DATE N L
INSPECTOR
I
I f,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
_
_$ /
Return Air
Steel
Combustion Air
Roof Deckvu
Exhaust Fans
O.K.toWrap
_�
F.A.U.
Framing(/
�- 4
Compressor
Insulation
/�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
p
A.,Wh
Prywall - If
Z� Q
Coy
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
I I
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
Q
Encapsulation
Gas Piping
Gas Test
GO
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)