0111-127 (RPL)IN
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
Date I Signature of Contractor—
OWNER-BUILDER
ontractor
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 STAT F, FUND Policy No.
(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 Ianner so as to become subject to the
workers' compensation laws of California� and agree that if I should become
subject to the workers' compensation l3rAisi6ns of Stection 3700 of the Labor
i Code, I shall forthwith comply with those' prrovi'sions. 1i
I Date: / Applicant �S, V Bio
-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 jof this City to enter upon
! the above-mentioned property forinspection p `rposes.
Signature (Owner/Agent) t^�� -� Date �)
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE � 0
APN
ADDRESS �...C7•-151.1 CARU,.IUACrjMf
OWNER
CONTRACTOR /DESIGNER / EN (NEER
LYNN ,ROSE
M7t'AGE '4V'i'+1TRa MM'(TM
`>i`_d.,til l CAMULN C'OU'.�tT
75080 ST. 03"M R14 ffk
LA Q1(ilZ'3TlA. GA 9223,11
PALM LEMC C/?. 942:1
571
USE OF PERMIT
ESTMA7iTD C;CYt'T OF CO1!TSMifisf.""�;C9ff
I.W.00
FAm Ck1PCK F`.1:L 101-000-439-318
COAfS'i'ti.%f(:T10?d FM 101-000-4 18-006 �]:�.Oi►
DEC 13
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$4.1.25
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$0.00
T MAL FMAW ME N DUE NOW
RECEIPT
DATE
BY T FIN E
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 C
Compressor
Insulation i
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
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
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)
Final
COMMENTS:
77�,Z
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Bin #
City of LQ Quinta
Building 8T Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
ON-/�-J
Project Address:
Owner's Name: L & co I
A. P. Number: 6-6-6 1Ca KV c L G ao �wr`
Address: s_G GA GU v/t,Yi
Legal Description:
T, Zip: 44 k. 7-g, �
Contractor:
�fjZ:tTLelephone:
Address:
Project Description: ?9 vL
City, ST, Zip:
Telephone:
P
State Lic. # :37Ltf F 9 :37L
City Lic. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
hone: x.
State Lic. #
Sta
Name of Contact Person:Q/ /"y �� L�a�
Construction Type: e:
Occupancy:
Project type (circle one):: Nev Add'n Alter Repair Demo
Sq. Ft.: # Stories: # Units:
Telephone # of Contact Person: 7., o !-4ro f 2
Estimated Value of Project: lt'9eo U b 6
R A APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
aPlan
Sets
Z
Plan Check submitted 30
item
oust
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person /0/0
Plan Check Balance
Title 24 Cates.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2"d Review, ready for corre ons/issue
ctrical
Subcontactor List
Called Contact Person
lumbing
Grant Deed
Plans picked. up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
Jrd Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called C
A.I.P.P.
Pub. Wks. Appr
Dapermit issue
School FeesZ41
AU&L 444LI
Total Permit Fees
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