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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
&10934 B
Date Signature of Contractor
OWNER -BUILDER DECLARATION
oww".(
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 .HA?IONAL UNION Y Policy No. ITS -510.0
(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: 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
BUILDING PERMIT PERMIT#
��-��� `TRACT
DATE VALUATION LOT
4 J�1/24177,163.60 1 e0303-1183:?023
JOB SITE
ADDRESS �Y•'��%F�.�.T'�i�.�..�)��e���A.rT
APN "18
r i64-27
OWNER
CONTRACTOR / DESIGNER / ENGINEER
S: A.L:.r'4, Q€.IW.U_,C
9HEA 1I0 WS
60-:311 RIbOGY PA'1?JCWAY
81.260 AVENUE 66
1A Q'JWA. CAS 92253T'.
ivl,AL CA: 9280
(,909)8-.43-8996 CBLA 6616
USE OF PERMIT
it l? • LOT IA PLAN 354SC (7A7 S.1-0. CASI'TA & It'E AP P hTIO MT.
AS S.F.) PEPIMIT DOES NOt MCL -VIDE E's60L'-T:WAZ,L.S, POOXi, SPA OP,
''Lik?Si►LrWAY APPROACHI woo,/ C D
CUS71ohl C'fJAi.IM. UCTION %06&09 SY
I VIOPCHMA IPIO 636.00 SEP
GARAWtCAR—POICr 45610 sr
i.yUMUIs'i: CTICR4 FEE 101-,00f)-419-000 S91213D
PLAN CHFXK PEZ 101-00043 -31€4 $7741.0A
MECHANICAL FEE 101.000.421.000 193100
L•Ef:'I'IZ1 1 1 T 101-000.420-0W W5.00
PLWA13 NU!',17;9 101.000.419-000 314,00
STR.C?NG NOTION ION F' E - RMM 101-000- A I -AOA $17.72
011ADINO PER 101000.423.000 $15.00
DEVEIDPEIt ➢A14MCT FEE 1A,4g5.00
FEE. DEPOSIT 101.000-439-318 47S4.00
SLIF3-TOTALt.t�1�1�Zi�c ��1d Al�:i FL.f�� �13�f�
$1,447
1. ESD 1RE-PAI.'15DM3
4750,00
Af�.t'4 �a :£'1v"'1a;1V�1.'JF � :S 1'�'17�, 7!1'C►VV
�4fC,�7,f>f+
RECEIPT
DATE
BY
D FI
INSPECT
v'
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 p3
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
IoD
Final
Final _
BLOCKWALL APPROVALS
POOLS o 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 , I
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 7�—
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power _
M1
Final
Utility Notice (Perm)
COMMENTS:
Cie(_
LICENSED CONTRACTOR DECLARATION
. I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp. Date
6A0974 1~LLJ
fi'30iU3
oZ Dated d Signature of Contractor
ca O. "� -
r— I.- C) OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that lam exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
C'') () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
0C
d Q WORKER'S COMPENSATION DECLARATION
CrI hereby affirm under penalty of perjury one of the following declarations:
p () 1 have and will maintain a certificate of consent to self -insure for workers'
K W �: compensation, as provided for by Section 3700 of the Labor Code, for the
D
� Q performance of the work for which this permit is issued.
Q U ( ) 1 have and will maintain workers' compensation insurance, as required by
LO: Section 3700 of the Labor Code, for the performance of the work for which this
i — permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier NATIONAL UNION F: Policy No. 70135309
r, C
J (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, andiagree that if I should become
subject to the workers' compensation, provisions of Section 3700 of the Labor
Code, I,shallforthyvith comply„withxthose provisions.
Date: tt' Appjicant
I <-
b Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $106,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. i
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 l+
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;inspectilon purposes. j
r b.-.�.. �...mw,
Signature (Owner/Agent)-- ' ` Date
BUILDING PERMIT PERMIT0 ;.
-118
DATE VALUATION $177,163k0 LOT 122 TRACT
r
JOB ADDRESS �E1.6wI6fRi� , i'M1.�TMIX��iJ. E
APN 764 -
w
OWNER
CONTRACTOR / DESIGNER / EN (NEER
8F.TiE Lk QT.JST7' 4 LLC
60-311 TRILOGY PARKWAY
81-260MMM, , 62
J ikQu'11djTA CA 92253
71URMAL CA 92K)”,
(909)833-6996 (MVIA ' +3
USE OF PERMIT
SINGLE FANMY I7W3= - DSKY'
•,0
arU - LRJ1 2,62; t'ikiA 530= (laid OX, �M.01- .f3 b4.4s.t.�i-o1'.-.�Y.11it. t . .. .
315 S, Y.)?,9AMfT 0O.E5 WOO INCl,UDT•; 'DLOCY,: W.A.MA P004 SPA OR
I)Fi3.'irEWAYI APPROACH
CUSTOM CONVIR11CTION 2,068,00 SF
PORCIV!?ATIO 536,00 sip
C A RAGEIC.ATIrO1•YT 456.00 SF
RUM coat OF Cons""T]RUC11"l Bn
.r.+,
:1.7'7�.t63.dSCi'!
ryp•y ry�a�(�+ erg y1��};�y�TF
' rD,tiStiAYJ.6d. FRE NITAD�1It
..
CONSTRUCT "N IT&L I �Fa ^ DLA -313• (i9 ��I �1 °d1
4y
PLAN CHECK FER 1,Q1-UQC1-439-31TS V7 i.44
.
MI � 'Ihk,MICALFEE 101-000-421,-OOD R93.00
ELECTRICAL PEP $113.00
'
PLUMBDIOn�r 101...-000.419-000 t148,00
STRONQ MOTION PER - 119SID '101_006-241 -OOD
aRAD11,4 I PCIS 101.000-42:3.000 £1.5.00
1
9L*' E,L0P9R IMPACT IVFZ VS40J.00
Y
.ME DRPOS1T 10I.00b-439.318 4M.60
'
i
SM -TOTAL: C0K8 T.F.i.1:T0M0M A.1•Jird'�+��'Tp.�1yk-�3�1CHPI'CK
$4,4411.66
y
50.00
ASA
-- _ JQ TOIAL PERMT FEE'S DIN. NOW
$3,697.66
.
MAAq�?;
MAR 2 A
CITY ov t A fsi�ilJ
FINANCE C'r•pi:
i
RECEIPT
DATE ;r,.
BY 'l /
DATE FINALED
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover i
Equipment Location 1
Underground Electric I
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 l
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
FHrArinr Rarantar•ia-c
COMMENTS:
/
- ..
1
`�,,•_�i;._ 'tors