0110-071 (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 g Exp. Date
yt�atew s/ Signature of Contractor,'
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 wagesas 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
1 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.
(,4) I have and will maintain workers' compensation insurance, as required by
S4ction 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 �d��.ATEDA3IJ I Policy No. �S iDJ-t�lli23�
(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 oflSection 3700 of the Labor
Code, I shall forthwith comply —WRKthose provision
r(Date: Applicant-%
,yer ice.. fl_ I
.l_I :, I�«�.,.,..... `:,� ''''",;'"`.�', " •, r.. ,:,,•
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
ful a ptlmil Subjeul lu the uuitdllluns and leslrlulluns sel iuiLh uii I_Ils
application..
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes.null and void if
work is not commenced within 180 days from date of, issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby iauthorize representatives of this City to enter upon
the*above-mentioned property for4G1;ecti6`n purposes.
Signature (Owner/SAgent)�.f'+f \t%* ..':LDate, t
BUILDING PERMIT PERMIT #
011.0-011
DATE + VALUATION LOT TRACT
77
- as, ...
ADDRESS' E%% C°Y.x+FC.�1lllessV_l7J.JLt�ed1
APN °�• A�
OWNER
CONTRACTOR / DESIGNER / EN (NEER
9'a68RM1Ptif'U;;8U1 102
°IU -40171 IGHWAY 111
SIX 1)1C c'; Q, 92131
3 .r'S t F1Ifi3'1'x CA 92M
C160>17IN3363 ' CB1.41 4V?
USE OF PERMIT
3I5TOXX I<: M1Y.X I;3W'is'1:.1'.W3-
3VD _ LDT °3'0' PLAN 3H. IRMIZINI".I' DOES NOT INC'1,110E at. -OC K WAI.A s,
'*001,9 PA OR. i)MT''WAYAi'.PWACH. IS%F'LAHCFI12("K T FF, R.1;MICTION
FOR, ISSUANCE OF A11L1'L TIPI.t7M," TYPE
`i'f3e3C-T 0Y: 10.11 1C 6f4 IMS$.Do 031?
PSis:)1lNr'a'IC3 3rit5.00 SF
0AT104O1? CAiLPt R:T 60100 ST?
X&TR"M COST OF CONSTRIXIM011
21316,72-1%)
F,Wdv!Vf VIEW SUMMARY'
C`.CSNS'1'3t11MIUN MIS 101-:000-41 tl-000 s1,038.s D
K.&N CI`•1FCK MER, 101-000.439-318 $214,07
MEC,HMICAL l"11;1? Oil"
t11�;G'.itz1CAL, FrXe, $171.17
1''UMB1140PTI 101.000-419.000 $191,25
OI��t. i lG�1Jd�fiE1iQ'
qp)amo we 1,61*000-423-000 $20.00
;t�a�s{'gr3.;C31Pii��i IIl6b?;t3>e'-I' I<>S�F �•t � '. $P,PU°7 t30
tal•YT 1:Ik° PitBUC PLACXIk • R1?3 E 270 -MID -445-000 r1o.I I?
OCT 15
?001
;� YBi ft 'AL • t3 MZUC"A1:ON AND l':[...w t'1F:I"m :c
$3,690.04
CITY OF LA QUINTA U20 PRE -PAID F' ?E1
'�
$0.00
FINAMCr 0"PT. P�
FAiSLA PO
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RECEIPT
DATE
BY °Y ,J
DAT FI QLED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
� 2
Underground Ducts
Forms & Footings
L_
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Decker
_ _
7_� f%�
Exhaust Fans
O.K. to Wrao_
F.A.U.
Framing - 3.-a 2�
S
Compressor
Insulation
_
G�__ _ — /
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�j
G �C
Final_
3l G'�--
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines G P
_
� d y . dZ
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer ConnectionO
Encapsulation
Gas Piping
Gas TestG
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
-2 3( CT2 —
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
Finali
Utility Notice (Perm)
7, _ —