0210-010 (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
674,374- B I -RIC 1/03
Z i7
DateSignature 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 & Prof essionals•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 S"f. TF,FUND Policy No. 046-026 <n
(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 provisions of Section 3700 of the,Labor
Code, I shall forthwith comply with provisions. ` /)
D"ate:,"'/ ��'• Applicant f
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, 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 isnot 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,.inspectlon purer fses.
Signature (Owner/Agent) • I Date ' 1
BUILDING PERMIT PERMIT #
t
DATE VALUATION LOT TRACT
S220,85100 7 2,9437-3-
56/
JOB SITE
ADDRESS X19.-% 4�iD.� 1101A QUYN CA w R -17W
� .T�
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
ID Okt `,3.F`RT a31?'M. OPNQN r
OPARY13 CON81'.Ll:ii/MON
PO BOX 1716
7 9-2 95 RMC HO 1A QUIN'J:16 gel;,
LA QITUTV1 CA 92253
LA QLf'11;11,� CA 92253'
(`36op71.Iq. 11 (:.B7114. 299
USE OF PERMIT
1�?'CrT.� T.�1�Tt.Y1a'tJi1�i,.uT?�C1
SFD - LOT 7, ZNC;.t N `O 1. PERMIT JD0 ,S N(.Yt' tNCLUDfa' 11LOCIC
WALLS. P0014 ;lidA OR D.RM i+'AY APPROACH 7.5% Pr. AW CiHTf CK ITER
R1:-OUC' ION ;FOR MULTIPIX 13 3UjkNCZ OF RMW PIAN '.P. PY
CUS°FOM C(.'*1STR` 1C3JON 4635.00 S:P
PORC IPATIO 201.00 SP
91ARAC(MA3'1'fJRT 6100 31W
C��CDS" oil CONKTR rt:,�110n
"JAsuo
7y 'per �9'� . gyyy(��ffi,('�,'�[Xyrtl€►1!�s7y'D
CONSTRUCTION I � 101-000.4,18.000 $1,063.00
MAF4 CHECK FEE 1014=43,9..319 �a1'a.arG
INIEC1ia1,MCM,YZE 101r009-421-000
Et.,FVrRJQ1 L itur 101-000-420-000 $16101
PLUMS 401+'12 101-()00-419-000 31.25
STR.f•JNO'MO'1ION FU - 3MID IIDI- 00-241-000 $22.09
ORADING HE 101-000-4,23,,000 .91.5100
FA V i14�1�11b? IMPAC7 FEE $44foi..,00 .
AA T1 1'i>P PU011C P LACr'M - MESE 270.000.445.000 $12.13
. 1�ld. W.r0.LALi C4../.lYT, 1—XTJCr1 .71Y"AND ,C'1.:A CJ.7.ta�iS.e.J\
$4,22.1.3R
UM 7f?1FDRKED FEW
$0.00
D d 4e P�?`•1�1NI, n"'VES tDrU, now
$4,7.41 —is
OCT 3 U 2001
r clrr of LA QUINTA
✓
RECEIPT
BY
DA E FINALED
INSP
INSPECTION RECORD
7
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 2 —
F.A.U.
Framing ZE
Compressor
Insulation J -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulaticn
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-
Final
BLOCKWALL APPROVALS
Final
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
,/
Waste Lines 0 - _ ¢r Z .�7 5
Gas Test
Electric Final
Heater Final
Water PipingPlumbing
Plumbing Top Out e -
Final
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 Concuit
Rough Wiring ✓ �d
Low Voltage Wiring
Fixtures _
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Pow -.r
Final -
Utility Notice (Perr)
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