9606-079 (SFD)U)
H
N �
W
O 0 ch
r- aLo
W
Z r-
O T
JLIWL�
F- W
U)
Z
t+')
LID
N
ON
U_ (3)
W Z
Lo �cc
0
X W
m<
CL
rnH
,'I -Z
Cb 5
� d
Q
J
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. Classy Erx'p".,Date
7.14ER8 t3 f,� / ,. i.,013,
1A17>
Date" Signature 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-projeot (Sec. 7044, Business & Professionals
Code). I
O 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 .-&INITI, INS• -CO, Policy No. 042066WI
(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-aspto become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3_700-0411e711bd
Code, 1,sh'all forthwith comply withro osep ovisions:• -
Date:"'!%��1. Applicants `- ''� "� --•"'� i''� -�' `r' y-��;
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and:civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the 'conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City,"and State laws relating to the building
construction, and hereby authoriieirepresentatives of this City to enter upon
the above-mentioned property for inspection.purpo$—_
Signature (Owner/Agent), - - -Date�F
BUILDING PERMIT PERMIT# CONTROL# '
533
DATE L • ATION ¢�{���4� nn 09 ��.f�jj LOT' 1 y�+}� TRACT
3-4 {�IC 2�
�•/
JOB SITE
APN
ADDRESS 45-240BRIDGE E.EWAY t
604-3*2r-�1 5
OWNER °
CONTRACTOR % DESIGNER / ENGINEER
C;HIM1JRY C1.tONi rU1,L CC: NINI1. N1'1'1F!
CE1vr! iky C,R.OWEL L CCiNIM1UWrIES
1.535 so. "zS"rkCCI', sre. n2oo
1333 SCS. MDH �"I'RELI, S'1`.. #200
SAN BE1ZNAW1N,' CA 924OR
SAN BE'RNtllitlil O CA 92408
t 9} 031-6 �
(909 381 61}07 QUO 2120
C��
FSir.LVJi�IWN ,i�LiUFLiTZ A°Wr_
USE OF PERMIT
/
S1TICBLE: FAMii,y i3'WF1.i,ijv�
459 RASSERO AME,
250
PJ.AN 3C`R.
TRACT CION rTliE.fC ft0N 1.445.00.SF
C3 A1eRAOFJCAP.1'C'iT.2"!: 05.00 S1;
E'ST&WED COST OF C,WNSTRU 1710N
9et,9if9.5ii
P1F RMIT .P.CE .ti4711 MI AR`lr
J 1_A.N C;NJ»CK M 101-OQ1143s'-3111 S5114.94
Qr?NR T RUC 1'100 FVX- 101-000-418-000 $5:00
fvJ'6 HAKJC4-L VEX 101-000-42,14M 947.0
E.LECTR1C&(,", FEE .101-0,W 420-000 $111.38
101-060.419-000 $148.00
3111ONG MOTION FEG -10. SID 101 -CM -1241-000 59.09
ORAUTNO EE9 101-0W42340 0 ' 520,00
"I Ft RAST RUC TURF FF: 225.000-443-•3e12 S2.�tf5.4
'0 -4 rc�NS"S 1t cJC'1417:'r ANLL .1 i�AAr CIMCK .
►3,4$s.3s
,
LESS PkE,-PAi.11 FEES
`WR PERMIT FEES OU E NOW
S3,485.31
A.I.,
E t
-
RECEIPT------
DATEBY+
DATE FI ALED
INSPECTOR
a
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 1111 Y
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath Z
Drywall - Int. Lath
Final
Final
BLOCKWALL A P OVALS
POOLS -SPAS _
Steel
Set'Backs
Electric Bond
Footings
Main Drain .
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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 AP ROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:'