0202-232 (SFD)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
'101039 B THC 1131103
De - -�� Signature of Contractor / 1 d5'
OWNER -BUILDER DECLARATION
t:
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 3760 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
,�p'ermit is issued. My workers' compensation insurance carrier & policy no. are:.
Carrier Policy No.
SIMS MD i 00046d8210-01
(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 provisi?Mof Section 3700 of the Labor
Code, t shall forthwith comply with those r 'sons
Date: �'""r-�"? Applicant—
Warning:
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. i
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, indemnity
& 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 fofAh
sNiction purposes.
/rSignature (Owner/Agent) 4Date - 7-0 �.
BUILDING PERMIT
DATE VALUATION LOT ()202-232 TRACT
J/^I/% atu♦ p 7y .}ry(',Cn
'Mj() 7 Sr .6 964
JOB SITE
APN
ADDRESS ry�
9-05RA,6`CHO l'.I:EI.V P,CKi MAJ,
OWNER
CONTRACTOR / DESIGNER / EN INEER
Ngi
°r:•.
T�'99JJy .�qq p pq�. 7 7
.�•.%I.Y(i.S lJ,pJ; 7, 2
.bi.4Si'L s v �A.�C J.:�%oUffiSVV 1910
9968 I �:� urc `' t"I'..qurn. 102
78>401 Y I3T01TWAY 111
RM ]:+lECrO CA 92131
XGA QUINTA CA, 922x3
760)1,3363 CWt 4W2
USE OF PERMIT
081TTQJ X FA15WrLLWG
SM.) - LOT 7° PLAN MR.. P1 RWI P DOW NCS';' I7dM1}D ; 81A ICK WAI,:I-34
P0014 SPA OR DRrVF,'4fMY APPR0ACH, 75% PIAN CI EXX FEE
KEDUC:TICSAg IrOn KU1,11PI;'S IS -3 UANCE OF SAME PIA13 TYPE. '
TRACT 02ONS'ilif9CTION V72109 V
` r
AOR.C,'I,PATIO 526.00 SN'
C1AP2AWCA1P' Wt 648,01) SP
�
tF y�
PUMM.IFER 911 AWAR
CONSTRUCTION "X 101.000.418.000 $963.50
PLAN CHECK FEE $199.0
MMMANIMU, FEE 101-000-4;V-000 SP2.$0
I .
l: UCTRIC'.AL 2+'ZA 101-000-4.2'0.000 $157.48
PLUMMO O i•FA 101-000419-000 5191 i25
STRONG MOTION FEE, - RMID 101 -000-20.'1-000 $19,19
ORADINO PRE 101.000.423-M) $2.0,00
DL"JZL±C)PEAJAAPAar"
•' P r. V'C!"J.`..d'.ALC0.11•l:S`NC.EA.V:i.'b,CMl'A..S'Y.iV CM45-C,
:�•:3, '�1..'
4
FEB 2 7 2002 IMMI Mi DUENOW
93 . '31
RECEIPT
D�ATEJ
BY /
DIAT•//E/FINA/LLED 2
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- 2 - 2
Underground Ducts
Forms &Footings
Ducts
Slab Grade
O
Return Air
Steel
_ z
Combustion Air
Roof Deck
,.
Exhaust Fans
O.K. to Wrap
0 L_
F.A.U.
Framing
z4C
Compressor
Insulation
- -d
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- d
Drywall - Int. Lath
O
Final — Z
Final
BLOCKWALL APPROVALS
POOLS - SgAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Tey '
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Q2Heater
Final
Water Piping11
Plumbing Top Out
�.�
Plumbing Final
Equipment Enclosure
Shower Pans
_
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final _
Utility Notice (Gas) -- — —
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit /1
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service _
Sub Panels
Exterior Receptacles
G. F.I.
moke Detectors
amp. Use of Power
anal
tility Notice (Perm) els-vZ
COMMENTS: