0206-039 (SFD)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 # r t�Lic�.. Cass - -,fj Exp. Date
78691 9 B .[li.`:
Date �" ���Si nature of Contractor
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 STATE FUND Policy No. 229.01,001=11
v
(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 previsions of Section 3700 of the Labor
Code,�Lshall forthwith comply with those/p�uisl s
'b
ate: 1./ ! 3•� 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 po-rson at
whose request and for whose benefit work is performed under or pur§uan q�
any permit issued as a result of this applicaton agrees to, & shall, indernr i1�J1
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and voi
work is not commenced within 180 days from date of issuance Of s
'permit, or cessation of work for 180 days will subject permit to cancellati n.
I certify that I have read this application and state that the above informatio Is
• correct. I agree to comply with all City, and State laws relating to the build
construction, and hereby autho-rri- representatives of this City to enter upon
the above-mentioned property foorrJl spyection�puurpoosses.
°Signature (Own 0 ant) /%1 f '`r� -` "� Date " �'� C ✓ ! =L
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACTJOB SITE
ADDRESS 52••6k2lr.AttUtwLAC0JJ ' APN ry:t1. P-0t3i
OWNER
USE OF PERMIT
CONTRACTOR/DESIGNER/ENGINEER
PAUL GOWZ-J CONIVRUCrIlMN, INC.
44-500 t3&AND CANYONLAM
PALM DFSCRr CA 92260
,760) C.T,ft 5710
$914 ;sY, SSI), PEAMf1 t' I)OF-S NOT IMC:;L t.OLp ii3:C M W1+NALL. UP, P001,
CUSTOM C0140TR11CTI.ON 1 0%014>0 01~
P0114CHIPA716
1,w.00 YF
0i1.1'i.A93FJOARPORT
11420,00 9s'
EA1.i.RbC%KM b.•' I's1A (11F Fa ON 11.7rR,USrrhYL%N
COKSTRUCTI 044 YES
10+1-000-418.000
$2,747."
N L,&.W,C.:H 2tit, FEE
101X000 -4n-318
$2,142,12
FZ1�; UEP021T
101.0W-433.318 .
-511,2110,00
M9CHAXJCAI.F 4 -Pi?:
101-000-4.2,1-000
$204.' 0
I;'L.1•:•CTR1CXL FER
1101-000-420-Mo5412,30
MUYdi13IN D Fez
101-000-419-000
$292.73
V1110140 MOTION WE- MOD
101-000-MI.000W31S8
l'?RA.L711.10 M,
$35.00
MELOPER IMPACT ITE
$2,00100
PIRE.C1SE 'PL„A14
$1 w oa
AR -A' IN PUBI IC 1'X..ACM,`.4- REVIL
M-000-14.5-000 145-000
81sa� ,45
t� • . ,. .."A�. 1010'fiRtlMIJ014 AND P1.A9
R Fria rTFPA1JXFER3 41,250.00
SEP 2 0 2002 MT&I,PKIMI MrS A PDTIM
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT DATE BY DATE FINALED INSP
INSPECTION RECORD I
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs M q h t L5 --c
Underground Ducts
Forms & Footings
LA
Ducts
Slab Grade
(
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.Kto Wrap
F.A.U.
Framing
- Q
Compressor
Insulation
-f
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
'
Underground Pltg. 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 /�i0� ,
Appliances
_
�Uo/' �i�� �''S
_
%oZ�� Q3 b'2�
Final
COMMENTS:
Final
JST— I-
Utility Notice (Gas)
ELECTRICAL APPROVALS
lr'V S 517
Tempa Power Pole
Underground Conduit
l3 d 1 �` eF.Tw2- '-� or < < - U 3 /4
Rough Wiring
Low Voltage Wiring
% J-?
Fixtures
F
Main Service
Sub Panels
-
�gS�/►^.rz �- t`s—�o �(il^'` l - r 3 o
Exterior Receptacles
/� %��1 51��2-✓t t�119�
G.F:I.
Smoke Detectors
d�
In I �( �S �j' �.a /'�-,e l
Temp. Use of Power3
Sue or:;Iv � Ada✓.� T{, eG. f7^_ #3Cf3
i-�-�'��-,(Z,�/3/'-
Final �r
Utility Notice (Perm)
5�
06