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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
/Date :2 1516 / 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.
Se( ) I have and will maintain workers' compensation insurance, as required by
rtion 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & olicy no. are:
Carrier �'MTE FUND Policy No. 0t�20130
(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 besome
subject to the workers' compensation 6vlsions of Section 3700 of. the Labor
,-Code, I shall orthwith comply with thos trovi ' s �
Date: w '��" Applicant `- ' f
Warning: Failure to secure Workers' Compensation coverage is unlavrful a d
shall subject an employer to criminal penalties and civil fines up to $100,00 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 f r Inspection purposes.
Signature (Owner/Agent) t� "`- Date
y
PERMIT # ,
BUILDINGPERMIT
01,11-lcm
t. Q e rkJ�Vs+,�5.7 LOT TRACT
DATE Y VALUATIONpl
�
JOB SITEy' �a
ADDRESS 755. �ck�A '�,O�is�ONJi�
APN
OWNER tL•
CONTRACTOR / DESIGNER / EN (NEER
SO€l"1'.ri5+1 14 MILT.S DEVERL{i1:"WINT
NAT LIR 1, kITE S
I.1 to t 1390n ' 17 fflU.rI DP,:t6'E
73.1960 103HWAY 1113 ffUf M, 5-
LAQUJN A CA "922 3 •
PfiJ M .DF*S +R CA 92260
(136(()568-6726 KBUt 5220
USE OF PERMIT
POtal..^ANVOR. SPA
! i 1s1,�4C` ,�i'1 P1i)!�FT� f' 1T kiRPL TIs�+Ar, POOV fit?L1fl+ditENT
2rB3CLA):;d.DRE NOT rNCL'UDED,
P001, tl,NLy10.q 3?A 17,000,0t► LS
1?nrSIMAT,C09r OF C0N6n?VC:11Off
ls,°?',t.VOW
PLAN MX11.1 W. 101-000-439-318 $11,"? 00
CONSTR.LIG';I'tO% FEE 101-000-418-000 $19.0.00
MECHANICAL FPL - F001 . 101.100-1,21-000 524100
1a1�C 'tirc��,il. ,1�1s1+ �� 13f c�L sY: 101-^000-420-000
P11111V&Ia;NG Pit — P0011 101.000-4.15E-00 %27,00
]6i0
nFr, 13 2001 - -
CiTY OF iLAQUINTA
F1N.,k sC PT
ULYA:1WAL, C09T1=TtMYat`ION AWD PLAN C IMMI
s'LES0 P R,BKIPM :t"I &')
�a.c1U
TCYXAL rYRMT,=$ DTX, NOW
4
RECEIPT
DATE ,
B �,...-
DATE FINALE
D INSPECTOR
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
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
l 446-9= I6� _
Final
Gas Piping
ISN p_A
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
Sewer Connection
Gas Pining
Gas Test
Appliances
Pool Cover
Encapsulation
_ _ _ (�_ _ _
6 ��(✓�d— _ _
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Condult
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)
Ci of La Quinta
Developers Project Approval Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
after approval. Contact applicant for resolution of conditions preventing or delaying approval.
Project: 1 Single Family Dwelling
Weiskopf Partners
Tract 29147-1 Lot 52 57-755 Black Diamond
Applicant Contact: Mr. Read 771-1761
Application / Circulation Date:
Date
Community Development Department
L v"r6t -a,,
Christine di Iorio, Planning Manager Date
Public Works Department
Steve Speer, Senior Engineer Date
Building and Safety Department
Greg Butler, Building & Safety Manager Date
City of La Quinta
Developers Project Approval Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
after approval. Contact applicant for resolution of conditions preventing or delaying approval.
Project: 1 Single Family Dwelling
Weiskopf Partners
Tract 29147-1 Lot 52 57-755 Black Diamond
Applicant Contact: Mr. Read 771-1761 g p 7 C G G
5-- � y
Application / Circulation Date: 713 D
Date
Community Development Department
Christine di Iorio, Planning Manager
Public Works Department
Steve Speer, Senior Engineer
Building and Safety Department
Date
Greg Butler, Building & Safety Manager Date