0210-021 (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
674 BBIC__ r 'tomi1G1
04
Date ' t' ' Signature of Contractor
L
OWNER -BUILDER DECLARATION
1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 STATE AMD Policy No. 09bb-02000'1 9$
(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 th—at\if I should become
subject to the workers' compensation provisions�of Section'3700 of the, Labor
C,gde,,l_shall forthwith comply with those provisions. t
....,Date:' -at c "• Applicant
r ;
Warning: Failure to secure Workers' Com pens tion 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, 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.
(,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
i �} �; ,�� �:..
Si nature (Owner/A ent) Data
BUILDING PERMIT PERMIT#
M10401.
DATE VALUATION q� y LOT TRACT N Q
JOB SITE I
ADDRESS 79-9€15 RAM -7110 LA QIMT .DRYVE
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
113 DRUM S'tEVF'_-l: PI&Iw '
VAR" +C0l�'43"7t � ILTMILIN
PO BOX 1716
'79.295 .LRAI,10, X) ISA, t?,"MM1,Dl:
L4; QUIMA CA 92253
LA QCl"Li�'M CA. 92253
(760)7'11-1941 MA, 29-96
USE OF PERMIT
SINGLE RMLY DW 0
FD* a LOT 18, IW. CANTO,1: PERMIT DOES 14f,2't` N4 CLUDE BLOCK:
WA1. A I"(J04. SPA OR p}1!V PWAY APPROACH VA' PPI CHE..CK PEE'
11213UCTION VOR M1.11:f1PLE PSO L'ANC E OF SAME >r+LAW 'r I&
C`03.i f,)M'9YONSi.1. LF.UCTION 2,693,00 HES
1'01'Cf. liMAITIO 267.60 SF
GA13l1MCARPOR'T 61.U0 OF
EMMAIX0 Cl?GY Ole G0�l;r"M'UC7.10 7
220AN12.00
COIdSTRIIIMICANt FEVs.-'. 101>006.418-000 '1;1,0vuo
1a.1:AN CREC K FEE 101-000.439-M $211990
MECHANICAL RE 3411.000.1421.000 $105,00
F-LECTPUCA1, V99 101-dDW-420•000
1'1.r11MBING FEE 101-000419,000
STRONG MOTION MR. + Rig ID101-000-241 -NO
ORADINO V99 101.000.423.000 fis.",
DEV LOPER lMl'I3•.G„'i' PEE $7,405.06
.FRT IN P11014C 3'lsACM , R, HIE .2707..000.445.000
El C31 l4 r0 1iT g
TfllAIL�� l����1yyA
w
y�3�iy�i�hODd
I.FM
/A'1�..300
( 'G>1�,t�ie i^.'�.H.li' '.i' $!?w' :S 17 NOW
OCT 3 V 2001 '
.v
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE,ry
JPYJ
DATE FINALED
INSPECTO
5�?IY..irryi,i
INSPECTION RECORD
am
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_ ? _
Ducts
Slab GradeReturnAir
y
Steel
Combustion Air
Roof Deck
.. 3
Exhaust Fans
O.K. to Wrap
3_ /—
F.A.U.
Framing
2_
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
BL.00KWALL APPROVALS
POOLS - SPAS
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 Lin
Heater Final
Water Piping
_ _
Plumbing Final
PlumbingTo Out
P
�.-
Equipment Enclosure •.
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation -..-• -
Gas Piping
_
Gas Test
_
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 23
Low Voltage Wiring
Fixtures
Main Service _
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) G
COMMENTS: