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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
70 39 I;3 DTIC 3x1/05
bate �� Signature of Contractor17 ! ���°✓
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 Policy No.
STATE FUND' 00L- 164881347,
(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 tothey workers' compensation provisions of Section 3700 of the Labor
Code, I shall orthwith comply with those provigis
Date: ° W Q , q 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 Ins ection purposes.
Signature (Owner/Agent) �./'tiJ./! Date � A l
BUILDING PERMIT PERMIT#
DATE -y i VALUATION LOT 031.1.-127 TRACT
169 29436
JOB SITE
APN
Y
ADDRESS 4+` ._525 7310111011' DME
l�is'r 140-Wi
OWNER
CONTRACTOR /DESIGNER / EN (NEER
IVAIT BOE LA QClbrfA COVE, LLC
IMILMS WKST xIOiT:i3.M INC
9968 IUDEUR.T 8'x., 3', 8M. 102
9968 M�iT'S ST 102
SAN .l IE0-0 CA 92131
S,AN T ►l EGO CA 92131
(858)653-3403 aSGO 45x72
USE OF PERMIT
'� ([
ETLLMSJL�tL', FAt�2EL Y 3D' LPY F,.1l.1LNG
;;P'17 • B,.O'i' f.&9 d'L.A'h? 3f:. PL�I't�;IT I:IO:I�S :zviC7T i1VC1.LJf3J? ITitDC'f�'W'A,Li:S,
P001.4 SRA OR T.STI.t'l�`I's"�'.AYAPPROAc.`H
TRACT CONSTRUCTION :033.00 S
PG11dVIVIIAiT1.0 814.00 S?
GARACJLICA R POWC 672.00 8F
FIS"IDrl IT0 C01173" OF e".'O.1 "I'.1:?`C3MON
i881689.30
Pxt.RIVR d' FP59 93ili .tMMW
CONSTRUCTION NLr. 103.000-118.000 S9SI.0Ct
PLAN CiiF4K FEC 1011-000-439-318
MRC HANTC"ALFE9 101-000-421.000 MAD
L;kXf:'I" Iti° C.A). FEE 101-000-4201-000 S I Fe.10
PLiJMiI1040 F&K 101.000-419-000 $186.50
TRCYI40 MOTIOIw YEE • R'ESID 10 V0.87
O AT;)INO FEE 101.000.423.000 515.00
►XV-11'1,.0PL'',FZ IMI RA 'T I''RL $2,405.00
FEE .PCIP03I'a 101-000-439-318 4-15010
8111€ -TOTAL T'AL COId'61R1:TM(OR AND PLA2v CIRMIX.
Vs,611.84
T.AM PRE—PAID MMc)
-.fi750.00
D e AL I'.1:U1►.(B 1M DUE. N0iiY
FES (0 6 2004
CITY OF LAQUINTA �..-----�
RE EIPT FINANCEINVIII.
By '
DATE FINALED
INSPECTOR
..s * v V
or
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
j /0 �
Ducts
Slab Grade
— C' -
Return Air —� T —
Steel
7, —,Ir —
Combustion Air
Roof Deck
—
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 Wall Firewall
Exterior Lath
- /
Drywall - Int. Lath
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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
- ^ Al
Heater Final
Water Piping
_ _
Plumbing Final
Plumbing Top Out
�7 —
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: 1-7-10 Z/&,/