0109-071 (RER)t , ,LICENSED CONTRACTOR DECLARATION'
_hrereby affirm under penalty of perjury, that I am licensed under provisions of
FChapter 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
744'M8 :Ltt:`j0IY35M 03i31dx:
Date 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).
( ) 1, 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.
Wt1?R'IZIM, NATIONAL WOO), 01I
(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 those provisions.
Date: 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.
Signature (Owner/Agent) < �- Date 91,2
t ,BUI NG PERMIT PERMIT#
�} ,>
DATE VA UAT N i LOT[,fi ' TRACT
JOB SITE APN
ADDRESS
OWNER
K91, 110A `MW1'MPJ1rYJ.7R ASSOC.
516.144 PGABLVD
3:A qI.1:1'brv: CA 92253
USE OF PERMIT
CONTRACTOR/ DESIGNER/ ENGINEER
RO Yt?,d..,MAn 1'1KW:td+JCK XNC`. r
42-600 QXR01230, COURT #) 01
1)AT A1):4+SPE T CA 92211
REWCA Y RA' HRnOM .M)OR TO ]MI TER101Z 3SJMJ1.
C;09,r OF C:ON:s°�;Iri`UEMON
Ir�:rdZi+� "° �i'�"�i." t�r6l�t�lt�i��'t`k" • '.
x LMf;1�.Ky. VER 101-000-439-318 W133
(:;QWSTR.1)CT1014 FEE. 101. 00-418-000 539.00
91.-1rt"TRIC.&I, VEX $16,50
G\
v .
SEP 28 n li `
CITY OF LA
FINANC77
4=
STID-1"IMM., C0I,MM.UC_ TION AND PLA14 c''iUXX $80.55 -
•
LEI 53 PRE -PAM Y1133 $0.00
r i
RECEIPT DATE BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs i
Underground Ducts
Forms & Footings I
Ducts
Slab Grade 1
Return Air
Steel I
Combustion Air
Roof Deck 1
Exhaust Fans
O.K. to Wrap } _
Framing { 6/3�b�
F.A.U.
Compressor
Insulation }
Vents
Fireplace P.L. 1
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation I
Condensate Lines
Party Wali Firewall I
Exterior Lath J
Drywall - Int. Lath i
1
!
Final J //�l� (X/
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs I
Electric Bond
Footings }
Main Drain
Bond Beam !
Approval to Cover
1
Equipment Location
i
Underground Electric
i
Underground Plbg. Test
.Final 1
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines 1
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out 1
Equipment Enclosure
Shower Pans i
O.K. for Finish Plaster
Sewer Lateral i
Pool Cover
Sewer Connection
Encapsulation
Gas Piping ]
Gas Test I
Appliances !
Final
1
i
COMMENTS:
Final ]
Utility Notice (Gas) i
ELECTRICAL APPROVALS
-
Temp. Power Pole I
Underground Conduit
Rough Wiring i
Low Voltage Wiringl
Fixtures
Main Service J
Sub Panels
Exterior Receptacles
G.F]. J
Smoke Detectors }
Temp. Use of Power
1
i
Final
Utility Notice (Perm)
A
Bin
CI ty`Of fa (�U117 to
'C
;, 8itlidma�dtS�fery `Drvrson
PO Box 1504, 78-495 Dile Tampico
permit #
Oid9 X071
[� Qufnta, CA 92253 :(760) 777170 2
L1 � Building A , ,APpticadon hln 'Tikking Sheet
Project Address: ' /�6i� /✓'�!/>} S' �►��SJf /3 G f�,.'-
:;Ownec'i Name:y 10,�F1'
A. P. Number.
7. ,:
' .Address:
Legal Description:
City. ST. Zip:
Contractor.��Teleph'one:
J i.
Address:
e27 jam/ ...,
Coq-71D�R/
Project,Descrip6on:
City. ST. Zip: lvl�l
,C� �C�2 Cw—
�— D
C s 1"V6 T// 40 o sa,I
Telephone: _72b _
7 s/o.
� oo
State Lic. # : ev [�
City Lic. 0:
~Con t
s ruction Type: Occupancy:
Arch.. Ener.. Designer:
Address:
City. ST. Zip:
j
Telephone:
i
State Lic. #:
Proiect tN'pe (circle -one): New Add'n Alter Repair Demo
S Ft.:
q.
Name of Contact Person:
S��t�j/v �dv✓ILZ
.
Stories: Units:
Telephone.#
of Contact Person:
s6s7:
.Estimated Value of Proiect. 7Oel)
APPLICANT:, DO NOT WRITE BELOW THIS LINE
a
Submittal
ReQ'd •:Rec'd.; TR:f►CkING PERMIT FEES
Plan Sets
Plan' -Check submitted a, Kµ Item Amount
al Calcs.
Reviewed. ready for corrections o
Plan Check Deposit
les.
#Title
Called Contact Person 4 9w Plan Check Balance s►
Calcs.
^,Plans picked up 7 Construction •
Plans resubmitted
Mechanical
Flood plain plan
Grading plan
'.'' Reyicw, ready fob Corr ons/issue '
Electrical •
Called Contact Person Plumbing
Subeontaetor List
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted Grading
IN HOUSE:-
'"' Review. ready for corrections/issue f
\ Developer Impact Fee
Planning Approval
Called ContaMPerson
A. 1. P. P.
Pub. Wks. App r
Date of permii'issue
School Fees
Total Permit Fees