0210-008 (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
674i�"3.4 Tela.;;
Date '"ter ' W / 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 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.
$4) 1 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 1aIT? D Policy No. 446-02COV7338
(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 wofkers' compensation provisions of Secti 3700 of,the abor
Code, I shall forthwith comply with those provisions �
Date: ""`'�` Applicant
r
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'
BUILDING PERMIT PERMIT# .1
DATE VALUATION .22o,1am LOT 1 TRACT 2945 7-�
JOB ADDRESS '19 9i ,9 R �� �. A QU94-.I�icA.1Sf e�o VE
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
AQDWA: CA 92233
LAQiilwa, Cl. 9225.:
X60)?11-1941 C1113LO Z996
USE OF PERMIT
183TWOLE, FAIMY D M.DVLT-Y
SFD - LOT �:NS'_�ICA'NTO I: PEkIMIT =,Z NOT 3,14C'.f.Uf3t NLOCK
WALIA POOL SPA OR DRiVEiY'AY APPROACH, ''7Sa,{t, PLAR3 i' HE(X ".9
RRDUC i ION FOR 1t,iMT1P1.. ISSUANCE OF SAME PLAN TYPE.
CUSTOM CONS°lTRUCT1O?N 7,635.00 SF!
POTtCN/R:3it267.000 sp
09x•GE/C&yyORy 614,00 S i
YSSUK TGOD OMMC3Yt CiEtSKRU4'7i10H
2.20X^'100 .
FERM T171? N'tTi I"N
CONSTRUCTION FRE l of i-000-41€ -000 a1,Of13,OG
PLAN CH1KC1: rVEZ 101 -0001439-318 $217.90
MECHANICAL 1!`1. L� 101.000-421.000 SID&D0
FJ,ECTf:ICW, PEX '101-000.420-000 $162.01
33.L13fitiB'WO TIME 101 ^00041. MOO $1'79..;x;1
STRONG MOTIO)i F Z • SIU 101.000-7A 1-000 $2.2,09
s'3tif1DDIO ,M&E 101-000.4r3-000 MUD
1)V'Ir1k1,PER Ify1P1' CT,FLPE $ ,405,00
ART IN 'PU LIC PLACM - R MM 270.0004455.000 $52,1 i
flUS-IC'°ALC04#'I1-K_,' 7C�;.d0 AND PLAIT
U0 d)RC`ppP-i1rA I ) j4Mqq
N11 �1�L
•$ o s��, 3E'�:ILMI'r 1"FESt:Dk-SE now1001
1
ffCITYOF
LA QUINT
FINANCE DEPT.
RECEIPT
DATE ';
By' t �/ J
DATE FINALED
INSPECTO
INSPECTION RECORD
y
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
- 9—
Exhaust Fans
O.K. to Wrap
- —
F.A.U.
Framing
_
Compressor
Insulation
- - Z5
Vents
Fireplace P.L.
z
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final - 3
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
A
Waste Lines
Heater Final
Water Piping
Plumbing Top Out
6�
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
:..: .
Sewer Lateral
/
Pool Cover
Sewer Connection-
-va-
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final l
Utility Notice (Gas)/ `
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 (Perm)
S
COMMENTS: