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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
rr�#�Lic. Class Exp. Date
fii/W�F.'Sin AZ 1 yl l�
Date 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 ISignature 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 df.the work for which this permit is issued.
(>)' I have and will maintain workers' compensation insurance, as required by
Se tion 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, FUND Policy No. 170362443
(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 thg,Labor
Code, I shall forthwith comply with tho4e
:D"ate: I .a.3 tA'XApplicant I/
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to crifdiinal 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 & eacti pers
whose request and for whose benefit work is performed under or Pursu
any permit issued as a result of this applicaton.agrees to, & shall, ''inde
& hold harmless the City of La Quinta, its officers, agents and emplo s
2. Any permit issued as a result of this application becomes null and i
work is not commenced within 180, days from date of issuance of uc
permit, or cessation of work for 180 days will subject permit to cancell tion.
I certify that I have read this application and state that the above informa
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 p-`uyrposes.
f 9:° .�^'.. 7r..•.r•;,.A f' ..°".y' is ^ <
,sig -nature (Owner/Agent) i� :J� Date
PERMIT #
BUILDING PERMIT
.
DATE VALUATION $107.1M.70 LOT 1 TRACTJOB
SITE
ADDRESS 43-7•601�ORMIPAT�1. URAIE
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
Ch Q�JK O,TX3.A S 330,
5i'U i.lria..k � a'rzr tf;,,;;173.B-1
5005-0, LJ�2.ANIUtPI i•LRIT,al-17.;A1
i'.,��71;j 1,f CA 92264
PA€ VI ISPRMOS CA 9ZU4
(760)325.4.25+
USE OF PERMIT
SINGLE IFIAIWLY DWET 11,1103
SK) , 141T 311, PI.A-N 18 PISRM..IT ; O&S.NOT ITIdCLUDZ H1A)1_7X WALL, -,-
POOL, SPA Cit %;.ttJVFWAY APPROACH. 730,"o ti EDUCTION TO P1,A. N'' CHiaPTC,
?K -e DUE, TO M'ULT1912, I03fsATJIC E OF SAAR rLA1`I TYPE
`k7UCT CONSTRUCTION t'nfi' A IF
ia4:WS: IPA'i'io 33.130 Mi
i COST Irl :T, l: U.l�817(fC."i1014
107,1W,70
v�y �t�ay y� �y�+•�,����;yV.nI.►'.I.'.S1iA.il
PT
GOIJI TRUC'I'F014FFT 131,000.418-S'4O $667.30
PLIAH CH F.CK FEE 101 1';x# $t1a7.0
;:t4T�S"kiAt�%Si L F 1< 101;,000421 -KV ad t.lyj
FLK `.r 101VIf1 L FIRP, 101 4ft-420.000
VIAMBING FEE :101.900.419.001 $14VIi
STilOWOMOTIUM ri'EF—AVIS1n 10't -$.00 -2,41 -No $10.11
-ORAT IHOChia:
p:k�V1?S.L±P1s".1t )HPACT FE -2, 05.JQ
All .:%i'SC''FlOE1'.eA%'`L,IJ'`'1C'.3.110
PR&P,A ��U;I
:JUN 0 2 20.03. ram P M kwT Yd ySLn:Evo
18,E4
ITY OF LA QUINT'
FINANCE DEPT.
RECEIPT
DATE v`
BY tit f
DATV19AL
I PECT
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 0
Ducts 9E 4
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
.,0
Exhaust Fans
O.K. to Wrap
—
F.A.U.
Framing
Q — /4-7—
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
OL
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
j
Final
I
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
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
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL' APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring . -/ - 3
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
6011' N
Final
Utility Notice (Perm)
COMMENTS: