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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
70187 F
Date 2 - 7 - .. `/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 coristruct 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 S1,�.7.L; Iq)121) . Policy No. )W263-62
(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: �l i , '�/ Applicant—,--'/
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 inspection purposes.
Signature (Owner/Agent)
Date :7-
BUILDING PERMIT PERMIT#
0,103-023
DATE /ry VALUATION LOT TRACT y
/ .. V $294.5 r+�:W ,i 28961
JOB SITE
ADDRESS gP0_9 7,r -81�.2�Aa.1:�CtVE
APN
7'75 -350 -OW
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
M_ V L& QL1WrA'70 LP
?ltiiMOVA' 7TE M' CIOMMUIATTIS, .tae,::.
200-L "t1'f.AINTlNGTON AVE. A100
2(s? E. �'�'.1.WHIMCI ON AM #1(K)
XscowlblmO CA 92025
ESCONDIDO CA 92025
(760))-8238 CRL0 5413
USE OF PERMIT -
i11111GLB.IWAILJarDW7L?a'a
SPO • Lt)T 3, PLATE .2AR. P0', MI I' .DOES Nt7C INCLUDE BLOCK WAL 1 3,
P=401% OR DIUVIRWAY APPROACH, 711% REDUCFT 014 TO PLAN
CHFCK FEE DUE TO MULTEPUI L."i tJA SCL' OF SAME PLAN TYPZ
CUSTOM C0NSTRUCTIOIN ,422.00 SP
POttCt PA'C1O 749.00 SN°
CIA,R.ACI1!#Cd RPOR.T MUD 117-F
9S'.;d:1I�;Qm".1�..I� d10sr CSF C:ON61A?M.S, ON
294,599.60
CONSTRI"ICTION FED, 101-000.418.000 $1,322.00
P AN C1- ECK PEE 101-0()0-4394418 "69.Q
M1~CHPAII(; AL P1•.L 10 1-000-421-000 S 143, SQ
FLLrCTIUCAL FEE? 1 U 1-010-420-060 10.4.'90-060 $x10.29
PLUMIttl O FEE 101-000.419.000 $179.26
:r!'k1OND MOTION RM,SID 101 -000 -241 -OW, $29.46
!3R ADI O FEE 101-000-4123-000 115.00
L' ML.OPJ:R IMPACT FXV, $7,405.00
.ART IN PUBLIC PLAC09 - ROW .270.000-445.000 $236 5f3
SUB-TTO'1'AL C:t MMMUc,i' 01.4 AND ; LA14 Ct:#1r.�'X
$4,910.61
4-A IJ
IAL YMM&MFEES DUE NOW
�,8:i.11tfi
MAR 18 :200:4
CITY OF LA QuINTA
FINANCE DEPT.
RECEIPT
DATE
BY
DATE I A D
INSPECTOR/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings D
Ducts
Slab Grade
Return Air
Steel_
Combustion Air
Roof Deck iI o41
Exhaust Fans
O.K to Wrap
F.A.U.
Framing e"
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath F� d
Drywall - Int. Lath 2
Final
Final
BLOCKWAL AP ROVALS
POOLS - SPAS
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 L3
Appliances
Final
Final
U61'dy 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)
COMMENTS: