0202-216 (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
'P�f10 D RIC
Date `% 747 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 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 th'e 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
SI.ction 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 . Policy No.
ST.A.T9 FUND W-11348813-01
(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 provisioms�of Section 3700 of the Labor
Code, I shall forthwith comply with those previsions.�s
Date:'- �; > i� �' 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
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety .
fora permit subject to the..conditions and restrictions set forth on'hls• ,.
application. r.x
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 abbvej6formation is",',
correct. I agree to comply with all,City, and State, laws relating, to the building
construction, and hereby authorise representativs of this City to enter upon
the above-mentioned property for' spection purposes:
5 Y 7-
a,
Signature (Owner/Agent) i %� p^�-�� Date !�"0;
BUILDING PERMIT PERMIT "
DATE VALUATION I LOT TRACT
JOB SITE
APN
ADDRESSG� 40 yANpFO 1A. i 0
.
jiJ["/V( N Uy �Kyw'�GLF"JV.�7q1f
.'.f
OWNER,
INEER
CONTRACTOR/ DESIGNER/
PM�a •p(• ��yy»•/yyy,,��rs� 7 .
.X A Q-1.//.LV�; ,N .[�l.�'^�.+.' �
vvy��r7�����pp }�me�gg ygp•�-�grp } ,+-�p��}�•��•p��y��y /q
•.1.Ltd]7.tlS 'rV1,11 "Yi114 8115.YO MiC
99,68r -'rim, ' M1LP_z€ 3LrA.`Y'V102
`13.4011° 1111 arIWAY 1 i 1
C& 92.131
LA, QMM -A 2253
(7fs0-),,714330 MAM 49172
USE OF PERMIT �•
MOL11 FpAWX 1)Wffl..1,,L]N 3 t '
31PO • LQ'. 47, P1AV 4APERUf T DOES NOT 114CLU-09 OL C11C
WAS..1,w�l, 0048 SPA OR DIME WAY .APRRO:A.CH
$'RACi T CONS'1'21.1 CTJION :081.00 SP
PORMPATIO , 666.00 Sly'
C1ARAC`{MMi PORT VACOO ?F
2300747.10
17:,L�..L6.1]9f.�.4:V .Cu� iy irdYA.�Y�1�kP..:d
CONSTRUCTION ME 101-000-4,18-000 $1,096.0{1
DYLAN C:HECX 199 101-000.4.39-318 9941.01.
YiE`r-'MAINIC.AL 'FCl? 101.000.421.000 roCa0
W.WTIZIC.A1L Nom, 101-000-420-000 S182.16
P71)X k111^IO f 101.000-419.000 W&OO
STRONOMOTION MK- ItWi,D 1.05.-000-24,1-000
CIRA1531vO WK 101.000,423.000
DIW1$LAIPP..i3.1>J31�
ART 113 PUBLIC. PLACES -1:MME 270.000.445--010 $7647
S4`'•-7 YeaAI.. C1 i't` eiTC l"TC�A nl�YiJ:lal. C .;CK
`bA,443 1
/R'. 1,.E+1.7V +R'M8'.E IP.6�J�10
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h lid. FEB 2 2001 u�'
CD Q ILSF�p(��1NgFJ Pt -S
RECEIPT.
<'�
DATE
DATE FINALED a{�� I
INSPECT
> .:
..w i!•s '7 PGa C..,..
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Sic
t •1: R. �.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING.
APPROVALS
MECHANICAL APPROVALS
Set Backs
—
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_
Compressor
Insulation
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
'
Drywall - Int. Lath
Final
/ —
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
Water Piping
_ c/_2-_ �
✓
Heater Final
Plumbing Final
Plumbing Top Out—Equipment
_
Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
"" —
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
—/
Utility Notice (Gas)
r
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring J
Low Voltage Wiring
Fixtures
Main Service
�—
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
_ ��