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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
,74 11 " A C.F3 ry 3 X11 ";A/2f
Date Signature of Contractor !� 1
t 1
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.
'604) 1 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 STAM9FU14D Policy No. ISM31 4-99
(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 Califo nia, �nd agree ¢.that if V should become
subject to the workers' compensation prolsi'ons AIL ecti n 3700ofthe Labor
Ce pode, I sh II fo hwith comply with,th � o
Date:- tApplicant
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 tbe.above information is
correct. I agree to comply with all Cit and St to laws relating to the building
construction, and hereby -author ze represent tives of tl�i's City to enter upon
the above-mentioned prope fo insjiectio�i p6rposels.
r'
Signature (Owner/Agent) 1 ate
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01120-061 TRACT
11,07 . , . $,11200.01
-
JOB SITE :
ADDRESS
77-180 eULLE E`GILY.1 A
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
3 '],yEr S01N
3N�' �E'It�ii'a't;�iWO
r-180 CALTZ COWIA
445.260 MAI ST,
LA QLa;CWA, CA 921233
INDIO CA 92201
(760)347.8913 CBI*. 4995
USE OF PERMIT
POOL AND/OR UWA
POw81,:HE 114 b"3..#kC9.ATPR_A'.P), 3T FR
AU= PZR.194,1 UAC; FOR VOR K SEWN'WITHOUT 81a29.YJINO P1rRMIT
POOkrAM/011 SPA I'll
E9J-11VXK= COST OFF C4:AMMUL3N
1:2,fmoo
3! �'>f3�MITE S: &VAIMAR
1yNESTIAGATIO3a FEE. 301 -000-423»,000 SI44.0
PLAN CHECK FET 101-000-439-318 $92.60
L4 i `7'�i9C�'xFc7 .I Fa, 1011 000-,418,,000 S1400
1dZ0 4, 3Q(_.AX,". 2--PGtt L ;101w000-4.21-000 U4,00
; L�C"ta 'RECL.t1,k, YR — P001, .101 -M-410-000 39a.�0
FILU �€Q.INO Y a• POOL1 Q� -000.419-000
DEC 07 2001
�1 YOFLAOUIUM
. FfX4A4Cc ,.,�
1AMS PRE -PAW FIM
$0100
axnA P�'+1�MC 1aS+u.9I "03UR 00W
$4.7760
RECEIPT
DATE / ''
i 7
/1;7
BY
D:2 FIN D;A n
INSPEC R
id r t j
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1 V -C_
OPERATION
DATE'
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL
APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel ?
Combustion Air
-
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
_
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final.
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste'Lines
Heater Final
Water.Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
`$power Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
_
Gas.Piping
Gas Test
Appliances
Final
COMMENTS:
(�- 5 — —e
2 �j� C12
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)
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CITY OF LA QUANTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
II
1 CA?E 12117 O 13Y
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
.NO EXCEPTIONS!