0308-057 (SFD)U)
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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.
License # Lic. Class Exp. Date
B MC 9 10/04
Date" Signature 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.
(N)i 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 OLD R&PUBLIrd :11dSU Policy No. . MWC10MV00
(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 thoserovisions.l
,Date:Applicant -• ��!��
f 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 Cabor Code, interest and attorney's fees.
.f
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 emplolin 2. Any permit issued as a result of this application becomes null and
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancel)
I certify that I have read this application and state that the above informat
correct. I agree to comply with all City, and State laws relating to the bu
construction, and hereby authorize representatives of this City to enterthe above-mentioned property for inspection purposes.Signature (Owner/Agent) A,r -Date�.
BUILDING PERMIT PERMIT# 100
DATE VALUATION LOT (i`i00105` 1% TRACT
i < a Sla9,is ^�.�iiD 136 29323
JOB SITE
ADDRESS C�i. 11� . + GR+�. ���
APN
63 .9-aRW )213
OWNER
CONTRACTOR / DESIGNER / EN &NEER
? NI_,LA ? 1-7k)V ,S ()b CAL:L€s0;IS:ca A
T.I✓"1:11;fAIR F TOlP s B OF CALIFORNIA
78 401 C a"17�'=I:1WAY 111
78.4.01 CMUHWAY I I I
LA t VNITTA Com.. 9215.3
UN QMN fi CA 92253
(760)777,0131 CUf 34M
USE OF PERMIT
Lam• Ap �(� V p��7'7 y y�y�y
".11.J.�i LTtR�L,I`t'61YJiA.S 1J W!.wl.wl.eLIV 6T
r
SFD .• LOT 135, .13LAf 0- N.E MITOO.ES NOT 1T1C1.iJDL BLOCK
WAI.,IA. P001,, SPA OR DRIVEWAY APPROACH, 73%, REDUCTION TO
PLXH CHECK. PEP DUE tO MULTI-PLE i9sux14CP QF ca,mmy, PLAN '1" i vz
TRACT COWS' Ft=1'10I3 2,225,00 Ste
1IORCH/PAT%O 53.00 SF ,
CA1lP�CLJt~AFI1'C+ii'i' 919,Dti 3TC
ISIMMMD COSE OF Cf3NITMUMION
129,W-1.40
CONST UCT3.014 HE 101.000.418=000 VM4,5D
PLA1d G m -m Ira 101-000-439-318' 'M168
MECHAN1GJ`t,7., nZ 101-000-421-000 M00
XLECTRICAL PFS 101-000-M-000 V,0918
P1 UMB11 01701. 101.000.419.000 $140.15
STRM40 A OT101i M.- RESID 101-000441-040 111299
GRAMHO ME 101.000.423.000 $15.00
1ZXFVE1X3P)M IMPACT iWZ 1ya,�o�.aa
S'CJ1E�,-TOTAL CON '181 R.UC11011 AND PLAN C.TFU
"� �,Ei�14.80
IMO PRE -PAID IBES
$0.00
DEC 15 , 2003
C� DI:� DATE f BY DATE FI L SPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Retum Air
_ ({' �✓
Steel
Combustion Air
Roof Deck
Exhaust Fars
_
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 17_
Drywall - Int. Lath
Final
_
Final
POOLS - SPAS
_
BLOCKWALL APPROVAL
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground EPIbg. Test
Final
Gas Piping
PLUMBING APPROVA
Gas Test
Electric Final
Waste Lines ,Y
Heater Final
_ _ _
Water PipingJ�
Plumbing Final
—
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral _ _
Pool Cover
Sewer Connection ,� e.o—Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
-
Final -
Udilty Notice (Gas)
ELECTRICAL APPR VAL
Temp. Power Pole
Underground Conduit _
Rough Wiring
Low Voltage Wiring
Fixtures oo
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
A