0005-201 (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
115 l 17 ,girl' D HTC
,,Qto .y 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 f 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 Policy No.
S TATZ PIT:tdi? 4t5.1-gg.41%{1SfI%fit
(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-shallnot 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 of Section 3700 of the Labor
C 19�e, I shall forthwith Comply with those provisionse�
„pate: � Applicant
, � !rf J':..� x.=! � l r' e' : 't nor--••..
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 1.80 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 for inspection purposes.e
10/B •r �rss i
JSlgnature (Owner/Agent) _ s -� •-a x,�� 'Date
BUILDING PERMIT PERMIT# 1
DATE VALUATION LOT �.,+�� TRACT
114 ?:tiC)A'§
JOB SITE
APN
ADDRESS
79445 CALYX 1'RC,WY,T?0 i
OWNER
'CONTRACTOR /DESIGNER / EN INEER
GSA. IVMWr A34D —111,1 AMS .A980E ., :4.9C,
OLPI RANT AND WW.i:A' A i AS«SOC.,11,TC.
P A 1M. �:.tL';,1}s�YY A CA 92211
i
PALM DRUM CA. M11
C160)2$45-7676 CM& 203
USE OF PERMIT
SPO -IDT I 14 PIAN 3RC / MR1,11T DOM :NICI ' 114iGLUM BI.,OG#C VIVALL 01€
k?L ALL C?7't1.ER P.M11AI1 O R.YrWL11".OT'YMA, Ei1?€.7t_` C f 1014 TO PLAN CHEC`.'ot
FEW FOR 918ULTIPIX ISBtlVNCK OF UARIE 5'i.AN TYP&
F�:� RC HIPAT1.0 t29.60 Sok
ppyy /
(1',A: n1 0PIT 1 /r) 42,504,80
q,A, �fat��:0F4(
PK"r rf YKE R?OMMMY
CONSTRUCTION IMM 10'S -01D 1-4t8-0('9) M6103
PLKH CHYXIC IVEY 101-001'1.4350-318 $162.86
MEICfiA,NICAL. FEY,' 101-000.421-100 "0.30
ELECT k 1=1 1` 1-000,42ti-Cl00 $336.49
F'1A,7I;11i3 WOPE1: 101.«000419.000 $164,50
SI RO24 C ttiLYFIGH FIS • Ptit+SID 101-000-7AI.000 X13.
T.MP.A,CT FZZ $I,9fY7.00
CON91-MUMION ARD PLAN CHELK
$3,266.."
:S SS 1?F2B-PAR)1 Z
$0.00
RECEIPT
DATE p/ fj
BY
DATE FINALED
INSPECTOR
(/r`
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs j {
Forms & Footings I I
_
Underground Ducts
Ducts
Slab Grade (
_,_
Return Air
Steel [
Combustion Air
Roof Deck j�
_ —� =%
Exhaust Fans
O.K. to Wrap I i
F.A.U.
Framing Il
_
/�
Compressor
Insulation I {
,lj
Vents
Fireplace P.L. 1I
_
t. -[
Grills
Fireplace T.O. I I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall j I
Exterior Lath i)
Drywall - Int. Lath I
J
I I
11 •
(1
Final I[ `6/z/
Final
POOLS - SPAS
BLOCKWAL>L APPROVALS
steel
Set Backs I ]
Electric Bond
Footings [
Main Drain
Bond Beam li
Approval to Cover
I {
Equipment Location
I i
Underground Electric
i I
Underground Pibg. Test
Final 11
Gas Piping
PI' UMBING APPROVALS
Gas Test
E
Waste Lines j i
3 (2
Electric Final
Heater Final
Water Piping {
Plumbing Final
Plumbing Top Out 11
Equipment Enclosure
Shower Pans I
�G'
O.K. for Finish Plaster
Sewer Lateral j {
l0/
Pool Cover
Sewer Connection 1
Encapsulation
Gas Piping
Gas Test j {
— • (yl �j %
Appliances ) {
I 1
Final
11
jt
COMMENTS:
Final
Utility Notice (Gas) { {
ELECTRICAL APPROVALS
Temp. Power Pole i I
Underground Conduit.
Rough Wiring I {
Low Voltage Wiring I !
Fixtures { {
Main Service I I
Sub Panels j {
Exterior Receptacles' I
G.F.I.
Smoke Detectors
Temp. Use Power] f!
Q/
of I
il
-
Final
Utility Notice (Perm) I I
(�� (�