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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 Division 3 of the- Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7631 fid B _ 131ID5
Date ='" 12• ^,l Signature of Contractor
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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 &r 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 FMID Policy No. 1.1588263-02
(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. /J
Date: %:' ' Applicant X"', e P rr r �-
±/
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
7th,above-mentioned property for inspection purposes.
Signature (Owner/Agent)=���'"rT•�i -,� Date
BUILDING PERMIT PERMIT#
0+0 -024
DATE_ VALUATION LOT TRACT
d`f4 29961
a
JOB SITE
ADDRESS W9W J31a.aLF(lm
APN
775^350-004
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CXSiIAQVINTA 10Z„P
NNOVA.a"'7VEi?. OR:T Cti;, a.Cs.t+ot' ISS,.DITC.,
200 :K VAR--RDIC*TON PINE #4 00
200 E:, WARM s'.Cdj N AW-. 0100
.SC°OkJ MO CA 92025
I7 -113C ONIJIDO CA 9202".
(160)81 9.8235 MIA .51413
USE OF PERMIT
SMOIX.FANMY DWELLING
SFD a 1Vf 4, 'PL„A1i 2C. PERMIT DOL'S'NOt' INCLUDE 0U..?CK'41 A1.LS,
tx0014 SPA OR. DRIV'r'WAY APP.ROACK 75 oto RZIDUCT.)ON TO PLAN
CHECK FEE OUL TO MULTIPLE 15SUA;NC'E 01r r"Z PLAID TYPE
CUSTOM 1001110TRUCITIOW ?,489.09 SP
POiZui/p.A'P1C1 —AS.00 SP
c1AR4.C3P1C`ARPORT 660.00 SF
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E5'OMTED COIS OF CtiNN RT7M?r'o7
294,599.60
C"CJNOf'IiL?CTrt313I;T+3L 101.000.418.000 $1,322,00
PW4 CHECK FLE 1011-01100-439-3115 $269,63
MECHANICAL F U 101.000-421.0100 S1421.50
MIEC'i Rit. AIIL FrIE 101-000.420-000 $2AO.28
I
.
PLUM. 83140 'F`EE 101.000.419.0001 $170.25
STFiONO MOT1034 IEEE • l2LSID 101-000-2.11-1'',00 $29.46
0=920 FEE 101-000.423.000 $14.00
O?Y91.0, PXPt I M11ACT FEE. a2,495.9.0
. 117' 1'eI PUBLIC PLAC U .. REE 3Ir 270.000.445.000 $2361so
-TOT 11.L CONSTATIfMON AW AM CT-1Cn1C
L833 MR -PAW MRS
ta,Qa
°1 AITIfs'3'r 1'. .q Dur SCOW
MAR 18 2004
$4,610,6
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
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DAT FI LED
INSPECT R .
.4 ;• 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 1111,1641 ZLe
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 Wali Firewall
Exterior Lath p
Drywall - Int. Lath 7
Final
Final
POOLS - SPAS
BLOCKWALL AP R - VALS
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 1A
Pool Cover
Sewer Connection Y
Encapsulation
Gas Piping
Gas Test /
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exderior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)