0210-027 (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
674074 D mer 7/:�1103
/ 1___)
Date ^ t' Signature of Contractor ' f
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 ST.AU FUND Policy No. 0464*0007M
(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 forwhich 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..th6fIf l`should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those pr visa s. 4.--
Date:, �� -�- ~� Applicant--`"
..� I
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 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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date 7 t
BUILDING PERMIT PERMIT#
0.2,f.Q-l12y
DATE VALUATION LOT TRACT
$,1<117.A!•1 24 TRACT
JOB SITE
ADDRESS `�9- 1- 7 VANC10 LAQUIRT i Mt.
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TD 1`3i;S.MT LN11�i'�LC1.k':Ar ENT
SPARICS G°i1N€�T'.fdUC 'ON
PO DcCx 1'716
79.,295 RA113CRO.L.A, Q"tll T AMM,
LAQUINT& CA 92253
LA.Q TNTA CdA 9225:4
(7600?11 � 1941 C'kIVI 29%
USE OF PERMIT
bRIMIX FAIMY
SM . LOT 24 ENCdA'i TO I P.iERMIT DOPS NOT INCLUMP, BLDCK ;
WA.1,i.,1`, P-004 0PA OR GRIM RAVAY F6PPR.OACH, 7514o PLAN CHECK F:R
MUC ION FOR 141EYY,fMZ ISSUANCE OF SAME 1'3..AN'i"�T&
COSTOM, CONSTRUCTION Z924400 33'
P011.MsPAY10 .255.00 SIF'
0ARAf1W ARPORT MOD 819'
13. MMTS,'I COV OF C'.OM11!'RUt^.`.TTeOR
240,117.10
1:°F.W- T IW #, , &!'D1d MRY
CtNaTRU(.!TiCJPI SISI. 101-000.419900 01,133.03
PLAN CHECK YEA: 101-000,439-318 $132.24
T,.�R%ff•"stTTTf,�k �� • lU1-i1�4i1t�1t3.(i ���t0,�0
Vaf>:s;°TI21tv.f L, 9171 3Q"sl-�i�O f11Tf �ll.�r9."en4
PLUMBRIG FEZ 101-000-419-000 171175
STR'.ONO A40`I ION IFF.2,', • RESID 101-000-241-000 VA.031
GRADi%tC'I KM 101.000-4.23000 51:�,Ofg
7
DrMll01Yra AMP:E V -f .e": 11y4�AP�.Of2
AM IN PtJtlLIZ P'OLM"S • :43fAlr 270.0090445.400 0100.20
f`t1t Ai scSa��°� c�� r D rx,T C11M., C
;F,tJ.�t�
D e T .3 aI X PAID TtIM3
vC 1GO
..PF,PEN ;FVn.SD1..7,
OCT 3 1U01
•:':`'',
CITY OF LA QUINTA,
. � •', .
FINANCE DEPT.
RECEIPT
DATE
BY ;
DATE FINALED
—�
INSPEC
INSPECTION RECORD
2-/
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
— 3
Exhaust Fans
O. K. to Wrap
F.A.U.
Framing
Compressor1-7
Insulation
3 Z ,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final I -c
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
2 - Z
Heater Final
Water Piping
Plumbing Top Out
Plumbing Final
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)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
' Rough Wiring 4j/
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final v
Utility Notice (Perm) .�