0110-067 (SFD)LICENSED CONTRACTOR DECL„ARATION
I hereby affirm under penalty of perjury that I amlcensedtunder 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 #L3 17?giic•�.�Class Exp. Datpe
yf�1.'
AM
Datei(-'�� �' ! Signature of Contractt
br•- 1-_ 4•+ ` '--^'ate
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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 contra :ting 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�(r) 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:
Carrieri� Policy No.g (y.bi1i312<3�i
(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 Qf Section 3700 of the Labor
Code I shall fortA h comply"wlth�those prAsG s! ( \ t
Date r Applicant i
L;.
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 oubjoot to tho .00nditiono amd roatriatiane aet faith 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, 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 authorise repreEsentatives of this City to enter upon
the above-mentioned property for,inspectl A n purposes. ;
� x
Signature (Owne�Agex)�3.3 h-°� --Date/'f'=�J�+
—
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
V29 7A0 '49 26964
JdB SITE
APN
ADDRESS, d a Atti�.
48 40 -01.5
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PbOA QY)TkrxA.
TRANS" Eff TiC;U; lNG lea"
s,96e1naria i"YPe,YY,?rm i o,2
78-401 7131415MAY U1
�N DIEGO C�»b! 92 i 3'�
-LA QjY.11 VfA ti �1 �a'A 92253
�� O;t?71-33G3 cn.Lft 49172
f
USE OF PERMIT
11) -1,0T T 4P .PJAA9 488. -P9P IT WE5-140 1:PkC1.,UD2 ,01.0Cr, WAi;IA
PO faM OP bRNMAY.3+.I',iRCyAC11.'5`I'a P1,A'tXF33:C`K E 53RMUC`f ION
FOX ISSUANCE OF MULT1P1;f,,1P1.A)1' Tln�F,
TRACT C0149'£1f"f.E0r,;'0N ::.,mml IDIS
POtx.Ck3.reATIO SF ,
0ATL40ke`CAkP0R T, 846,00 91?
PE'FlL3tt ,�'r,I IMSMI is
CCCOSTRUCTION M 101 -WO -418.000 S1,094,50
1, Lm miEcrt.mrs 101.06&439-3318 $224,63
UdItGHiNlCAL M. 101.066471-000 SMAD
$g.�y5��.__Ey�Cyv W ,�59 [�y{p 101-000-420-000 $19236
1;i11'.l:��., I,�i'i 7 �..•JSYJ Y Y:M1M1'J
1�� 1.1kag 11 O ,t•” ? 101.000.419.000 $1915.00
art-ni$N.1mcnrycw Vim - Raw 101.-.000-21,41 -000 322.05
~'(MAKING FER14)lY;fl00.423 -000 020.00
IMPAz,CT FE11:
AR1T1WPU91,ea1C 97110 wl21- �$F I1 2' dc,000.44 ..PJ'00 37.1.84
• A 1� i
lU,
a
H, M.C7C;'I"YC?1+1' AIM F LA CI-MeCK
$3,806.68
1WAL PYX&Ur MM DUX NOW
RECEIPT
DATE
BY �
D I E
INSP TOR
//': , ;� ., to !
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR ;
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
�—
Slab Grade
G S
Return Air
t
Steel • . Combustion Air
Roof Deck
_b2 _
Exhaust Fans
_
O.K. to Wrap
_��,4
F.A.U.
Framing
Compressor
Insulation
Vents
—_
—��
Fireplace P.L.
Grills
_
�_
Fireplace T.O.
Fans 8 Controls
7
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
G�a2�p'L
Drywall - Int. Lath
Final
Final
)
I
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 �,p
y, pZ �S
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
/
Pool Cover
Sewer Connection(�d�
— C�
Ertcapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
?Jn��
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lary Voltage Wiring
Fixtures
Main Service
Sub Panels /
Exterior Receptacles
G. F.I. 00,
Smoke Detectors.
Temp. Use of Power
Final
Utility Notice (Perm)
l/