0111-211 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 3 (commencing with Section 7000) of Division 3 of the Business and
rofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date' '{ ' 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 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.
( ) 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:
Carrier .STAR FUND Policy No. 046.00OM8
(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 Califia,,and agree that if I should become
subject to the/worklrs' compensa(ion provisions of Section 3700'�f the Labor
Code, I shallforthw�ijh comply with those provisions.
Date:, Applicant T� -_ a " ✓'
- 4
Warning: Failure to secure Workers' Compensation coverage is`•unlawfu and
shall subject an employer to criminal penalties and civil fines up to $100,006 in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth , on his.`'
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to -
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days,.will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with'aIl�City, and state laws relating to the building
construction, and hereby,authoriz, representatives of this, City to enter upon
the above-mentioned property for inspection purposes;; it
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0111-251 TRACT
M.131I " 44 29457.2
JOB SITE
APN
ADDRESS
49-215 RAMMO ]POW3 S`
OWNER
CONTRACTOR / DESIGNER / EN (NEER
1.1) D$...�S1 RT DTM1:OPMWE
SPAS (10NITMUC11914
PCS BOX ]? 16
d,9 -2X5 RRA.NCi01 A t'�"s�N'iA D.P.
LA, QU3�-T.A ids`j, 92253
L,A�1(pdi}T.Lk�3".('EA. CA. 5112t2d5 %
q q ritf G
USE OF
F
`PEERMIITy / 9 mWEp ,y y
SYD . to )T 44 PLttM M3. PERMIT VOES'34OT INCLt TZ, HW.b1r.ALLSt,
I'0014 RPA OR DRJVPW:AY &I'PROACH
0113TOM CO.M. I UCTIOW 4,243.00 SP
PORC.Illp'ATIO 522.00 Sbt,
SY.P Wii3OFJ4»A:f P0, ,T 710,003F
W�'A:,f ,TED COST OF CO.t':AS.SId`iJi✓�'0/.�,Y
_V1,38930
7pp, t��//���� yy �T7� (L, ��v*-ff77� ppm�t
��.tR.Tti.L'V. X1 9 �k 19 f7'4'.i11T O A
CXA10TRUCTI(M 1,12 101-000-418-000 s1,i:21,50
PLAN C°FiECK VERE 101-000-439-.318 $308.7.4
MWIRIVITCAL KE, 101-( 00.421.00 ? 36"„x I%
GI.ECTRWAL FE11 '1101 -00"20-000 $96. J
;j9LUMYtSNC IFU 101.000-4.1 9 -WO $203.0;
STRDW11 MOTION FEB, - RF—SID 101-000-241 -000 $35.14
C11Ri9,D.11'1'O FEE 1101-M-423-000 $20.010
0kVZW 3r,,TR IShcPAZT 1rM, $1,107.00
AstY .IN I'ilBUC PIAACE0 - RESIE 2 IN -000-4454M 4379.47
-�� ^ '.i • • f r d�1Mb6 'RUC7 JO `7 .1 ND Lid. *4 i.r.V:7.;`-•�A :.
s 1103' PRF•.PA1D FFKF-
S4,759,05
$0.00
TOTAL PERAW MS ;SUE NOW
0 6 2001
$4.759.I35
nFC
LATli��
CiTy OF w
RECEIPT -
DATE
BY
DATE FINALED
INSPECT OR
INSPECTION RECORD
r' OPERATION
DATE
INSPECTOR
OPERATION
DATE
�IINSPECTOR
a BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Z . z-
Underground Ducts
it
Forms &Footings
_ _ 2—
Ducts
di
I
Slab Grade
6- p'i. _ _
Return Air
Steel
— Z Z
Combustion Air
Exhaust Fans
F.A.U.
i I
i1
Roof Deck F.- 7 2
O.K. to Wrap —/ — Z
Framing
_� — Z
Compressor
_
i!
Insulation
_ c� Z
Vents
! {
Fireplace P.L.
Grills
�[
Fireplace T.O.
Party Wall Insulation
_ -
Fans 8 Controls
Condensate Lines
I(
t 1
i t
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
.
_
_ ^ �%— Q
Final
POOLS - SPAS
Il
'
BLOCKWALL
APPROVALS
Steel
{{
Set Backs
Electric Bond
{ 1
Footings
Main Drain
11
Bond Beam
—�S-L
Approval to Cover
I I
Equipment Location
i!
Underground Electric
{
Underground Plbg. Test
„{
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
II
Electric Final
i {
Waste Lines
Heater Final
! 1
Water Piping
Plumbing Top Out
Shower Pans
_ _
��'�
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
1
1
{
Sewer Lateral
Pool Cover
Encapsulation
it
{
_
Sewer Connection
Gas Piping
I
Gas Test
Appliances
Final
{
COMMENTS:
;
i
;
I
,
j
.
Final
Utility Notice (Gas) T�
ELECTRICAL APPROVALS
Temp. Power Pole f5 —i —
Underground Conduit
Rough Wiring _ 2
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
•
Final
Utility Notice (Perm) zo J