0209-070 (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 fr Exp. Date
701039 BHI.Q �f�� A131/03
Date% / `�'f'' Signature of Contractor`r°"�T'''o�!
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.
(f 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:.
Cartier ,T,;1,Tr-,V ND Policy No. DOD-1649W3.10I
(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 prpvisVj�!�V;of Section 3700 of the Labor
Code, I shall forthwith comply with those psovislons/
yDie:E+�;fit' Applicant_ ✓� '✓'y '
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 property forAnspectionr urposes.
Signature (Owner/Agent)"�`��� Dater'rx-
BUILDING PERMIT PERMIT#
0209-0110
DATE VALUATION LOT TRACT
�f�e
JOB SITE
ADDESS:.YS2n�ICa�1.c�S[.AsRC�rFrl
APN ZA9—�E�.
OWNER
CONTRACTOR / DESIGNER / EN INEER
i
SMIiat� (��TiAT� ? T�iC .
TRANS VMSTHOTIWR+WC
9968IIMM',`T°t„ 9tTfI22, 102
78.403 Y1311G WAY 311
SAW =00 CA 92131
LA (,3UM',€s CA 92M
(760)771^3363. MUt, 4972
USE OF PERMIT
RINGLI, RANMYraWE WO
511-1 • i,,01t.1, P1...AX .1A. tPZ0,11T DOES -140T INCLUDE 8i.,]CJC X WAU4N "
Z3V K
FSE F011 M€lY.i PLE WH01C E OF SAME P^I..X3 TYPE
YRAC T OCINSTRUC'i'1011 3.1999,00 VY
7aC1fid.taH!'3%itTIO e'Ji 108 wlr
0AMOWCA33 RT 662, DID SIS'
WXdA7:lfiaJCd o WITOF C1i.+,iV"t�A,YM(il..7lllyd.R
213,672-50
PERVIT .nY SUMMARY
C.ON's A°YIC.1lux,'Y1?m M-000-418-000 11,03,go
PLAN f:3r F K: k`EZ, 101.-000-4239-3 18 Ssi4.iri
Id RCHAHIC. ]., WE 101-000-421-000 to io
EI, 3:C:TOGAL, FEE l & CSZ-diltl-�a^C1-il�C r 1 Fi.!
PLtxMMHO ME 101.000.419.000 $Z O M
STROiDD&iTION11F ,USID 101-crb)O-Z41-00D, $21.37
MARDI(! FEF 301-000423.00. $Mlo
a3LPVXLOPF4R IMPACT 09, $:;,6 moo
-
ART W PUBLIC LACES - RE 1r 270 -000 -W -(W $34,19
IM -3 TyRrs- AID7083
$0.00
9�:-te7a�j+�tj�
04
OCT
LA
RECEIPT
DATE __e ,
BY
D FI A
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings /— - tq__2
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck — "
Exhaust Fans
O.K. to Wrap , G —
F.A.U.
Framing —
Insulation
Compressor
Vents
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Grills
Fans 8 Controls
Condensate Lines
/
Party Wall Firewall
Exterior Lath
Drywall - Int. lath
Final G -/ -' 31
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines Z=1212—_ --i L__
Heater Final
Water Piping
Plumbing Top Out oL—
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Shower Pans
Sewer Lateral
Pool Cover
_
Sewer Connection �� _ -3
Gas Piping
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Furfures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final •� _�
Utility Notice (Perm) ti