0305-116 (SFD)I
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) A .1 1a Date 1l
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
752884 B 19 OW 1 /2(
Date V ! _ U� Signature of Contractor `'�� / �I ` .
OWNER -BUILDER DEC6\RATION�
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&RC. 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
Sebfion 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 , FJITJL4IC INDEM14IT' Policy No. 1.167160)
(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,1 shall fo hwith comply with -those provisions.
Date: Applicant --,-X\ �" �•�� A
Warning: Faill. re to secure Workers,LCompensation c6ve age, 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.
BUILDING PERMIT PERMIT# .
O '.lf1�r•3.1d�
DATE VALUATIONLOT TRACT
ft'12,402.10 29 :29323-1.
/, (._.. ,
JOB SITE
ADDRESS 79-1650 C'OWIN 1ri1T�.L
APN 609 -38U -Q}.3
OWNER
CONTRACTOR / DESIGNER / EN (NEER
v0AFi71,.R.073A T-Tomm U, WC,
P01U)ETZ0SA HiDN i3 H 11'7C
PAU4• SPr-.WGS CA 92262
(703)187-710 CM24 2346
USE O�F7,PERMIT
F FAMU TjDWRy 1140
3FD - LOT 29 ,PLAN d.Fti I_ PLAN DOES NOT INCLUDE BLOCK
WAUTA POOL, ORA OR DRIVEWAY APPROACH. 15% DEDUCTION TO PI.A.r'44
CHECK F4E DUE TO MULT1PLw ISSUANCE OF Sad► E PLAN TYPE
. TRACT CONSTRUCTION
ION-
PO.RCWPAT'1O ?97.60 SF
GAM(%WCARPORT i 67,1100 ,F
•RE �y�ryy���ry �]+y /�t��u� y� �t,�y *r �y-y��r+� �[
S,l9 dA�lwalC�: ET) 4vYY T 0- k•\1.i7SITR4.�4v.L.CO
�! Ys �� g±�i
G,I2,41i?ALIO
1P NM Wk 8UW- MAR 1
C014STRUCTIOX FLEE 101.000.418.000 $39 ,00
PI.Aw CHECK: FEE 101-000-439-318 336-22
MECHANICAL THEE 101.000-42.1.000 $105.00
L+"U- 14CTRICAL FXE 101OC11', �i70 U00 $146.25
PLUMBING FEZ' 1.01.000 419.000 $168130
S"i'i€:l".NOMOT'ION IVEZ- R. ID 101 -000 -?ail -•000 $17,24
OUDINO FEE 101.0100.423-000 515.00
.
DEVELOPER IId!PACT FEE $2,405.'tr3
SCB-'TCy.'AL COTTSx' TJC.T. ON .,WD PLAN' CEWK
LESS PRE-k'A11) FM
$- 0.00
s
' ; 11AL 3I�.� FILES DUE NOW
JUN 0 6.2003
CITY OF LA QUINTA :
FINANCE DEPT. od
REAUIP-T DATE
BY
D FIyA /
IN
ECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & FootingsDucts
Slab Grade
i `'
,
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
— -
Exhaust Fans
F.A.U.
Framing
Compressor
Insulation
7
Vents �.
Fireplace P.L.
Grills s
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
✓O
al
Final
BLOCKWA
L APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground.Pibg. Test
Final
I
Gas Piping
PLUMBING APPROVAL
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
Final
Utility Notice (Gas)
ELECTRICA APPROVA
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)
COMMENTS: