0110-074 (SFD)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
70/1.039
Date-, _'41'el M Signature of Contracti5r
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 isnot 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 �fia.T:ts Policy No. i OR 0002
(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, (,.shall
✓ fo with comply witi Those provlslor�S.
�t
Date! t Pj °,+ Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, In
addition to the cost of compensation, damages as provided for in Section 3706 s
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a• permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if `
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize represe4tatives of this City to enter upon
the above-mentioned p ope.rty '6n
the
Signature (Owner/Agent), s 4_ } ;"^--^ °Date t�
BUILDING PERMIT PERMIT#
0110-074
DATE VALUATION LOT TRACT
I$zlo.7 1'.10 61 28964
s Ix.1
JOB SITE
APN
ADDRREESS 49-815 RA'JJ0kT.0 SAN PTLIM
OWNER
CONTRACTOR / DESIGNER / ENGINEER
-PM: L& 0+,?3,1t 1
TIS 1rRZr HOUSING INC
S1,9(*13FI'� T W111,MI 10.2
78-01 FERGHWAY I I I
% 3 fi3 d(s4 3 CA 92131
LA. QUIN A CA 92253
(76!1;7'71.3363 CUL# 4972
USE OF PP��ERRppMII�T,,
ff�� �� ��••;� q {�� q � / 7,
6J.ld\76.7%l.al',id'.1dtJ.C3.1...
SYD -.LOT 51. PLAN 4,AIL PLrQ&AIT nO.R3'NOT 1b1C1..UDY, £:LOCK WAI.1A
Y-100149PA OR DI#IVErW Y.a PPRO A01°i.. A. Vo Pi. NCIfECK FEE RED= PION
FOA ITSP Aii!Ci OF NftULTI P'L..S 7°ll.A14 TYPE
7PA. CT CONST RfJ(:` ION 00 5F
FORCI-iiPATIO 666.04 5F
(ULRACi1:N".ttiRPOR'f' 446.00 Sit
Ry�p';C�b�,s4,`I'M cowl, OF C:'(D?�I�i'#1I��a'�':Y ON
230, 747.70
yyyy��yy�n!� r.qq yy���y, ����� �;q�p�y�
P�i.1R&WI1' F L" ku C94� I&CA ..lC
C()'HISTRUCTIONFEE 101.000-4:18.000 S1=098,Ot1
PLA R' CI1iMX -FEE 101-0001-41.49-31 a V23.25
MUCI1',AAFMAL PIS ' 101wi�00�n,2ia610 i SIf4,tW
Y:IAMTRI'CIALFEE 201-000-420.000 �1a1Z i�6
P[..ISI>/i131Nf,1FEZ 101-000.419.000 $193.00
STR.ON10 MOTION ION "03 • ,RY- ID 101-000-24.1-004) $23.07
IJP' EELOPER MPACT FEE $2,�►t�7 U0
ART IN PUBLICPLACES - RUI% 2."�S000-445-000 $76.87
/++ I ?i(.'orfoll A14b PLAN ('ISM
$3,813.95
1Z.19 PRE -PAM 171W
CITY OF LA QUINTA
FINANCC:C.—f'T:>+1VM-MX1'�'.$t,=VIDE.NOW
�tt.t
RECEIPT
DATE
B
DAgE I ACED
INS TOR
L
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVAL'S
Set Backs
L--� _ p Q,-
- Underground Ducts
Forms & Footings
N
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
)
Exhaust Fans
a
O.K. to Wrap
F.A.U.
Framing
_
y �.
Compressor
Insulation
/ —
Vents
Fireplace-P.L_
_l—
-
Grills
Fireplace T.O.
_
Fans & Controls
Party Wall Insulation
Condensate Lines
;
Party Wall Firewall
Exteriorath
Llnt
O
Drywall Lath/
Final
Final
1
POOLS - SPAS
BLOCKWALL APPROW LS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
i
Underground Electric
;
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
- L - �2_. '
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
��� . p
Encapsulation
i
Gas Piping
I
Gas Test
Appliances
Final
COMMENTS:
'
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)