0110-073 (SFD)LICENSED CONTRACTOR DECLARATION 4
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.
Licensee/#y y . Liic..yClass ( Exp. Dyatre� y }pyre
rIE ,
r� Datet�` df �` 1 Signature of Contractor .�" � 't ' A �-
..-/ „ .y • v
OWNER -BUILDER DECLARATION
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.
a) , f 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 gl'.AT1'P,Fr(yW'+ Policy No. ; J•Q4 t3v 1 3d)
(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 provisionsyof Section 3700 of the Labor
Code, I shall forthwith comply with those'p�ovrs ons.
Date: 11'\ I, c, ,f Applic',ant t y1`14�
-' -V ..r
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 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 prtoperty for inspection purposes.
Signature (Owner/Qge t) 4 4. DateIL ��. - ' JA
1.
BUILDING PERMIT PERMIT#
&0 73
DATE VALUATION LOT TRACT
� lG . �+• ti 2€ 964
J B I E' l "
APN
ADDIBESS • �?3 �1 J � n C� s L a
XM -015
OWNER
CONTRACTOR/DESIGNER/ENGINEER
S�. I'A iy!,"LDI:'+i':4 k
T;MM WE:STHOU--SraG MCI
99681-flM T u'``'.1711i13j,ITE 102
788-401 F 1`11MMAY' 1:4.1
aAk:D11oGO cjd x2131
LA.Q7:,WA CA 9,233
(760)'771-3363 MA 4972
USE OF PERMIT
Mi
3FD * 1,0T 63 P1.!1341 1. CR. P IiI+RB.� 1301':5 iaU'I' IIVC t�J}73? 1. 'W;tv f.? ,
P001:�` Pp�A OR DRIV'k�'WA Y .��'191�OA("E)', ` .5% PI MIC'ldEC FEW, REDOC'A 10V
n~ k R: 13U.%3,►CE OF t1U1,TIP1A PI. AN T'Y'Pl?
r
T", CT CCrpd.lTRU%,CDON 1.41!72100 OIC
POR.C°I•' I ATIG 526600 SP
(MRAsC4MLARP011T d: 648,01 SIF
EWMATKU') Mtl'.0 MY Y COi�i� v i7 .'`M1`t
61210
C01161I'1 UC',i"10N FE7 101-000.418.000 WOO
PLAN CHECK FEE $19+1.43
MEC ANIC L FRE 1-01-000-421-000 89150
ELFC:,`i'RtG:AY. PEP, $15143
PLITM1 Oso "IF 1011-000-419cCA1 E191.25
s`i11.ONk U MOTIONFEE - k MID 101-00-241-000 $19,19
31 1)'INCI Fee $20.00
DVVZWPXR IMPACT .Fula
IU}
OCT 15 2001 tJ
1%ON A1rTt'} PIAN VF
$3,148.37
CITY OF LA !CUI4 rA U331 PRE.Patlw MI. M.
FINANC` r_PT•
$0.00
A'a-YE PMUM''13: .:15 JDVE NOW
° �0 3• '?
RECEIPT
DATE
BY''" '
D FINALE 0 f2
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
j�INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVAL'S
Set Backs
L% pZ.�
Underground Ducts
3!
Forms & Footings
Li
Ducts
Slab Grade
Return Air
i 1
Steel
Combustion Air
t [
Roof Deck
O.K. to Wrap
_
' �Q _
tom, _ �d_(L_
Exhaust Fans
F.A.U.
!
[
FramingCompressor
_
{
Insulation-�(p,
—
Vents
I
Fireplace P.L.
Grills
$(
Fireplace T.O.
Fans & Controls
I [
Party Wail Insulation
Condensate Lines
I
Party Wail Firewall
-
Exterior Lath
Drywall - Int. Lath
I I
!l
Final
I I
Final`
POOLS - SPAS
BLOCKWALL APPROVALS
�-
a
-Steel •.� r' ;
;1
Set Backs
Electric Bond
I C
Footings
Main Drain
G f
Bond Beam
Approval to Cover
I I
Equipment Location
[
Underground Electric
I I
Underground Pibg. Test
I!
Final
Gas Piping
I1
PLUMBING APPROVALS
Gas Test
[
Electric Final
3
Waste Lines
_ y Gam
Heater Final
i 1
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
I
Shower Pans
O.K. for Finish Plaster
I
Sewer Lateral
Pool Cover
I I
,Sewer Connection
Z �/_GZ /f
/✓
Encapsulation
;{
Gas Piping
[
Gas Test
Appliances
I
Final
! I
COMMENTS:
'
I
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
{
Temp; Power Pole
Underground Conduit
i
Rough Wiring
Low Voltage Wiring
Fixtures
i
Main Service
i
Sub Panels
I
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final - ,(
Utility Notice (Perm)