0303-119 (SFD)U)
N_ C/)
W
� (Y
' t1.1
� lY
Z
I- '^
H a Wr`
U)
Z
co
U')
N
OCJ
UQ
'+2Z
rH0
Q J J
m<
Ov
�M�
,-t Z
ob 5
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. Class Exp. Date
u�i0334 B ✓ . $ ��3t3ftT3
Date (!!!-., Signature of Con &K
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.
(�) 1 have and will maintain workers' compensation insurance, as required by
S ciion 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 l+i'ATTiO:IVAL UNION 7, Policy No. 703530-0
(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 ofection 3700 of the Labor
Code,l-shall forthyVith comply with those provisions
Date: 14 i k Applicant'"r �'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil.fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety r
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize rep esentatives of this City to enter upon
the above-mentioned property for inspe•tion purposes.
Signature (Owner/A ent� '� • .:Date
BUILDING PERMIT PERMIT#
DATE �• r VALUATION � Y ,6%��.7Q LOT 1^ v]' TRACT 30023
JOB SITE ADDRESS
APN
I-7W�1
OWNER
CONTRACTOR /DESIGNER /ENGINEER
[
0.HEAik XINTA, LIX;M
Z,4h MiMI
'
60.31 ] .rRIV)GX Tp,AIt.'�'V4AY
81460 A'V1 NUE: t"=$
IA QUIWrA CA _91253
"IMMAAL
CA 92883
t;M, )633.89ata
CBL;o 6876
USE OF PERMIT
UN= RJ :%.", ff4#: .L.'II G
'!°u n W x I AJ, IVLAP; 41331113; �13tK-� fiL11: u i.83 a.,{r.J rbKJV3 I A UU410
NOT INCLUDE [BLOCK WAILWA POO14 SPA Off, ORM.M4!'AY APPROACH
0C.7j
�
CUSTOM CONSTRUCTION 1,733.00''sF
FORC111laATIO 134.00 SY
0.A3IALGE, 'ARPORT 973,00 8F
XYrfAWYED C e`jMOF CilM.i.d.`6•9CM.00
149,013,70
MRMITFE7 SUMMARY
CONST RUCTION PM 103-000-418-000 $311.00
PLAN CHECK ME W9.43
MECHANICAL n 101.00".21;,000
Z1,WTRICAL 178E 101-000420-000 $:105.62
PLUMI DINOFEE -101.000.419.000 $116.73
STRo3NO Ia OTIOV ft'?, -REBID 101 Ri3M2.41.000
C;r"t.ADIWO FEY, 101.000-.423.000 $13.011
1'EVE1, PErl,.IMPA.CT ME
.�eNiykI"amall
S4,1 73. 10
IMS PRE -.CAM d77=?
r`
I it
S0100
I al
__- P3+...LUMT F3�''E's DUE NOW
MAIR tu?3
Cil f CIF I -A 74;11 yi e
RECEIPT
DATE,,
BY. ��j
FINA
44TOR
,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & FootingsDucts
D
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck 6, •O
Exhaust Fans
O.K. to Wrap p 3
F.A.U.
Framing 1115;,(D 3
Compressor
Insulation 7— _ 3
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
steel
POOLS - SPAS
,
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 a3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out LZEquipment
Enclosure
Shower Pans
O.K. for Finish Plaster
'Sewer Lateral 4
Pool Cover
Sewer Connection fl
Encapsulation
Gas Piping
Gas Test
.Appliances
Final
Finale
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 -�
Final
Utility Notice (Perm)
COMMENTS:
1