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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
7aSi4 B31.All
C
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.
(�) 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 PY.P1FDIC INDUMNIT' Policy Noi 13G71 �41x
(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 sh l forthwith comply with@hose provisions.
Date:_'LApplicant
�-- j
Warning: ailuro to secure Workers' eompensatio co` edage is unlawful and
shall subject an employer to criminal penalties and civir'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 of this City to enter upon
the above-mentioned property for inspection purposes.
` Signature (Owner/Agent) X�--✓ � ". d A Date w y v
BUILDING PERMIT PERMIT /i
DATE VALUATION LOT TRACT
28 29323-1
JOB SITE
ADDRESS M,640 (:0MYN EIXL L+A
APN
6M_380_=
OWNER
CONTRACTOR/[ / EN (NEER
POA%taEAOSA k10Nr W 1� Wry.
PONIDE 08A%rOlVil.8' H DIC
6671 0�7� T31t}"VE
400 s. FA YJNR 8U%r!? 13 1.03
PL -1 4ANTON 0,A
PAgM b'"�2Was CIA. 92262
(703)187710 MIR 2346
USE OF PERMIT
Si14GLE F'AtdX..Y i)V't72JA L1Nta
SFD - LOT 18 PLAN 313.XP, PIAN QO&S NOT INCLUDE BLOCK
WAIM,, POOL, SP'.A. O.FCDOVEW.€ Y APP.RZOAC H. IM16 Rrmtscrm TO PLN ,
CHECK FEE DUE TO kr4U7.,'i'`►£'l.,E ISSUANCE OF S AF. FLAN T YPE
TRACT CONST8,UCTION 3,951001 OF
PORCHIPAT10' Y 31D.00. SP
GAFiAONC.A.1tF OlUr 691,00 3?
Eb TdPi/iIl.'r9D COST OF C;ONS"IRUC1110
185,775-50
Pp: uvia T PER SI1b"dIl'JWZY
GONSTRUC'TION FEE 101.000-418.000 $940.50
PLAN CHECM ",E 101 -WO -439-318 $Ia4.81i
MHANICA,L FE1+ 101,000-421-000 $98,50
ELECTRICAL FEE 1511=i�00-t`�0-41013 � l3s. s&
PLUMUN40 I+ f. 101.0€ -000-419-000 81°78.50 ;
STRONO MO'T1CrN FEE PESID 101-0} O-24.1--000 81b.:5ft
ORADINO FEF. 101-000-423-000 811.00 .
DEVELOPER IMPACT !;'Eli• l�3,�fr35.t40
S►. 'I`( ,ia.CON; A"CU�'''JTf91�f AND PLAW ('1 K
$4,000.86
L= PILE -PAID FEES
$0,00
JUN 0 6 1003
R
CITY OF LA QUINTA
FINANCE DEPT
RECEIPT
DATE
'r..r:.z.
BY
D F A
INSPECTOR
ort
INSPECTION RECORD
OPERATION
DATE,--,,
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck
'
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
— _ 3
Compressor
Insulation
Vents 67
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWAI
L APPROVAL
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 APP VA LS
Gas Test
Electric Final
Waste Lines
-02
Heater Final
Water Piping
54 zzPlumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_ _
P,Encapsulation
Gas Piping
"
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICA
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
APPROVAL
.COMMENTS: