0308-225 (AR)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
343335 B C36 CS HIC 021211/2(
y 1 �
VD f _ :_� Signature of Contractor tiJ' r'. �!•. �_ • # a
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.
' 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 m -A T E I` in) Policy No. 729.14757-200
(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.
1 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) �.'i d Dates i -J I) s
r
BUILDING PERMIT PERMIT# .
0308-225
DATE VALUATION LOT TRACT
&37,401.6030 7.a3343
JOB SITE
ADDRESS IM -700 CAQS�Y1IL0WMI
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
BOB R1. NYAN
M L (:fgl.�r'�J� UCS' YI
713-700 CA-BRFL IA) WAY
54310 A'Vl~?tADA.TCTAREZ
LA QT INITA CMA, 92253
LA. C#M4'T�'A C.A. 92253
(760)564.4447 CB1;# 2051
USE OF PERMIT
RE"`3 MY..IAL AU7�1 L'IC;it.r
F]L+'11".A.t HED CA3ITA.ADDJTIM (M 3.1r.) WITH AT 1'A.CHLZ
CARAGNSTORAGE (7 06 4.F.), POOL CQUIP%4`FN1' WOM (807-5-1.) & ,
19LF d' f.:1P,RV)FN BLOCK WALL. 2061 C8C i
CUSTOM CONNTR.UCTION 274,00111*
Ir4AP,AGFJCfiJLF0RT '795.00 SF
b FT. WALL 19.1019 LFA
NNW", CCS' (aJF C'4)N 1RITMIO N
37,401.60
aPERMI' FUR su lRr diRy
CONSTRUCTION FRE 101.000.418 -ON $336,50
PLAN CHP.CK FRE 101-000-439-318 $761.60
MCCH"ICV, PE K 101.000.421.000 319150
&1,ECT1-jCAiL FRF 101%000-420-000 $40.49
P1.,S,fMBIrma FEE 101-000-4 19-000 $24.00
5Ti RO'NG MOTID14 Fmk: - REBID 1671-000441-000 $3.14
ORADY140 FEE 101-000-423-000 $13.00
SUB•TC)`M COMTRUC1101 f AND PLA1J' a, =1 " 1
�. $700.8,3
LWS Mr -i -RAM IMES
$0.00
DEC 0 5.200/ 3 `
RECEI
FINAN,
DATE ,+ �l
BY /
DATE HALED
�.,
INSPECTO
+� Jt�A�: d
C t:'
_l
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
3- 2-
Ducts
Slab Grade
- . y
Return Air
Steel
3- Z - y
Combustion Air
_
Roof Deck-
— - `
Exhaust Fans
O.K. to Wrap
�/ fid- 4
F.A.U.
Framing
_A9y -C
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 Q - ti
Final
rJ -
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
- /`g .-
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Z2-
Gas Piping
PLUMBIISfG 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
COMMENTS:
Final
Utility Notice (Gas)
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) 0 "X61