0210-009 (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.
License674074
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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 & 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 Policy No. 046.0200 MI?
(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 df'the Labor
Code, I sh 11 forthwith comply witOhose�prov sions.
Pate: Applicant ( �-
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. /
M Signature (Owner/Agent) Date
BUILDING PERMIT PERMI'(1
DATE VALUATION LOT TRACT
2.94, A,.
JOB SITE
ADDRESS 79^'967. MIDICHO LA QUINT& D i M
APN
I I -• — --
OWNER
CONTRACTOR / DESIGNER / EN &NEER
PO BOX 1716
LA, QUINA. CA. 92233
LA QILI NTA CA 72253
(7€0)771-15941 (MIX 2996
USE OF PERMIT
SFID , IDT 6, H'f> I A74T0 2: PFRM1T D0ra R+f.VV 114C1,U09 BU-*I,'K
WA.L , P0094 SPA OR FJR IMIM1A,Y APPROACH, 79A A -SLA' 0111YCK FEE
1t1=nUC T101d FOR MULTIM9 ISSU,A:l3CL OK SAME k'IANI,, TY4'X
CUUTOM 0011 ST.tTUCrION 2924100 LIF
PDXC".HAPAT.IO '61133.80 .SI.7
tsA AA0FJC,A_RP01VF 4, MOO SI;,
PMAW T.' E.9 � I- Arty -
CONSTRUCTION FEE 101-000.418.1300 s!^133,00
PIA -H Cmix put 101-000-439'-318 $23a.24
MUCKANIC'`ALFFF 101-*00.4ZI.000 $130,31
E,:,E.C'1`KICAL FEE 101-000-420-= $9,69.211
PLUMBINCI'F . 1.01.000.419.000 S17S75.
STK.OWO MO`i').014 FEE 4 MID 101 -000-241 000 $24.91
C` ADI'NO FEE ) 01-000.423.100 $15.00
:f?L''Y•EWPER IMPACT ME $2,400.00
ART 114PUBLIC PLACE19 - FX -ME Z10-000-445.000 $100.20
` « aug-1f0'i',f\T, C0N5I.°:f>1`k3t'F° 6.N1,TA PLAM CM
$4.,385,03
1� 1312F3�i'�413 tai ?`�i
$0X0
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OCT 3 V 2002
CITY OF '= GIUINTA
FINANCE DEPT. s
.RECEIPT
DATE
BY.
DATE FIN E
INSPECTOR
INSPECTION RECORD
4.
OPERA—ION
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 Fan§
O.K. to Wrap
F.A.U.
J
Framing
3
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 ✓ _
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
—oZ
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
— - o y
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas. ' L
ELECTRICAL APPROVALS
'Temp. Power Pole
Underground Conduit _
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Pern)
COMMENTS: