0312-027 (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 Division 3 of the Business and a
Professionals Code, and my License is in full force and effect. ,
License # Lic. Class Exp. Date /
763187 34
,Date �r` ° 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),- • •
( ) 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 STATE F0141D Policy No. 1683253-02
(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: / rl ' �' `r Applicant 6L2`71 V
�i
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on 'his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicator agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I' certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
q `
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
031210.27
DATE VALUATION LOT TRACT
s 2;115 :9160 43 28961
JOB SITE t c�sa
ADDRESS 80w i�iRUJIM �5:.
APN
775-:54', IfF
OWNER
CONTRACTOR / DESIGNER / ENGINEER
(TV L 0011. —)0, I -P
llwCJ'V'.A1iarasU2aCC}3viMUNIms, INC.
2001- ` ASITHRAM9 AN0? 's` . 100
200 X, 'ti'i AMM TON AVE fill 00
ESCONDIDO Cry. 92025
RSCOUDIYD0 1A 92023
(760)839-I3m C.i314 5413
,
USE OF PERMIT
i
SFD • LOT 4% PLAN WL pBRMIT DOA<S NOT INCLUDE BLOCK
WALL$, POCIL, 8111A 0 )PJVFWAYAP1'IIOAC H. 71 % REDtl CTIOH TO i' .K6
CHECK iTva, DUE f0 MULTIPLE' ISSUANCE OF SAME PLAY ,z YPW_
CUSTOM CO-AiTRUCTION 3,39.00 5F+
POitCH/1'A'P10 749,00 Str
0AIL,<!,.tIMARPORj 00.00 BY
I COS' O.0' COQ 9111 '1C,MON
294,559j.60
MOM ' 3'a'RR 8UIIii"RY
C014STRLTCTION FTS+ 101-000-418-000 $1,322.00
PLAX CH,EC`•1G' ",22, i 0 1 -000-43 9--.31 1.a ;,062 9.63
1t+1ECK"'i AL Me 101-000.421.000 $143,$0
+XLEC i RICAL FEE 101-.000-420-000 000 $310.28
P1111M 1100 FRE 101.000.419.000 $179.25
STRONC1,11ACITION FEE - RMJD 101-000-241-000 $29.46
ORAI?Tl O FEF 101.000.423.0100 $15100
DEVELOPER IMPAC!' YZE $4405.00
ART IN PUBLIC PLACES - RUIC Z70 -000-4- 0-M SZ16.50
-Tc CORMITICCON' AN D PLAW CM:CK
7.WV PI 171AIi9MS1
$4,810.61
$0.00
JAN 0 9 2094 TOIAL DUT11 now
CIT LA QUI NTA
F. ,CE DEPT.
RECEIPT
DATE
t:f ..�;4f
BY
/ ,
DAT9 QED
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INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
J 'y
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
L
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
S
Drywall-- Int. Lath
Z
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
I
Gas Piping
PLUMBING APPROVAL
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
A az
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring Oz
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COM NTS:
ate/