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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.
L;cnse # Lic. Class Exp. Date
DatSignature of Contracto,�,,,,�,„
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjuryrthat 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). t
( ) 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 I 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. .
N."'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 'STATH Ftft4 a Policy No. 1583906-01
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of�the rw'ork for which this permit is issued,
I shall not employ any person in anyfimahner so a�S, to becdme subject to the
workers' c9mpensation laws of Califorhia, and agree that if I should become
subject t) the workers' compensation provis gnsof Section 3700 oPthe Labor
Code�IS j�all forthwith cc ply'witlr)thos'e pr visions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer pto 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? alK ity, anWStatie laws�Felating to the building
a. i, r d
construction, and hereby aut�onze� repr/esentativesdof this City to ent upon
the above-mentioned propertyfor ins�pectlon,jiurposes.
Signature (Owner/Agent) r� � r .� j Date,!D
��l �'4+!.cj i ..
PERMITk
BUILDING PERMIT
i�
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS —135 C.�.E'i UK0 PHTV00
APN
772-=-M7
OWNER
CONTRACTOR / DESIGsN+ER / EN (NEER
�Y
IL' tT .�LI.tFAa..S U4
tv�i"i .1 i�I�+.rO a, OA gl , NIC.
S'ty BOX 810
1413 R, WERMTY' DE
TLA aMInA CA 92253
PHOENIX AZ 85034
(602)257-1636 MA, 4990
USE OF PERMIT
y
SPA • LOT 9:I P1,AN KA. P1wSi,h41'1' 'DOZES NOT INCLUDE BIZCX WAX. W
POOL, CiP,. DAtAAr AY.AMRO&Cfi. `A, '3A PIdW C1bl"st',`g; ftZ P.9D1IC1"10;4 FOR
ISSUANCE OF SJn;MZ PLAN TYPE.
TRACT COWTUMMON 3,191.00,u
piy ATI'% 313,00 SF
t iJG1.13AGPICAR1Oi'T "%00 SE
U, blzftlym COSW OF r, 0XIM713C III 01ST
1811.1979100
F 3 0:: 90M"iY
.MT
/11yJVr418-01ry0 $947s0
yaNSTADV-710Y PEE 101-000-418-0100
P AU CHPN I;. FFM 101-000-439-318 $812.433
FEE 101-000-471-000
Mpp E��yy�d�:+Eiyy`
,d4,t.0fW510
y �T�I��C�q,A.IJ
bkLLdlr !•RICAL ,119 101-00c"20-000 $204.95
I;LUMBI NOF'1!',E 101 -000-419-OW $2.41.0.
STRONG MOTION ME � RESID 101-000-241.000 $18.30
GRADINNO FEE 1,01-000-421.3-000 $20.00
DEVEWI 7P.1MPA T ME
y
WB 21MA:C. r"yc,NPT AW Mffil=
$3,907.70
1',EM P.FC&PAM F.0 lbs
X00
I=A T, PRE Wr T:i E5 DT N W'
,1Xi7.70
KA ay U 2
CITYOFLAQUINTA ,
FINANCOEPT.
RECEIPT
DATE
-BY
("' t
DATE INALED
CS
INSPECTOR >
13'
:.)
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
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_ U
Heater Final
Water Piping
Plumbing Top Out
_ _
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
_
Final
Final _2
Utility Notice (Gas) v
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
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)
COMMENTS:
, 11111\,v.. ► aiL 9 -9,2 rim