0005-177 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that lam 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
f97. 117 BITRIC /'1 CJ;�3112t'
Date Signature of ContractorP''�<°<
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.
STATE TFUI4I3 �6I-9�-GOOOt20
(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 asto 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. E ,�
Date: Applicants °.o,
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. 1 . ,
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.
�f P'
Signature (Owner/Agent)'`s� * -` �`' % -%'° Date 1./'7/"r.-
BUILDING PERMIT PERMIT#
000S477
DATE j VALUATION LOT • TRACT
.259,53
JOB SITE APN
ADDRESS w_294 cAu pALLl :.`TCS -019
OWNER CONTRACTOR / DESIGNER / ENGINEER
G.1::I1�TL. Ilk °L Al`T}7'CLd'Il'.. IAM ASSOC;, INC. Mt1TfIAATT MW WRJUAMS -4350C., WC.
778900 AMMIR OFUM Ui'Aam 7'7.900 AVENAM-OVIM ST °
PALM DPISIM 6A 92211 ',PALM. DESE : CA 92211
(60)345-2626 .5203
USE OF PERMIT f -
SIM -LOT 27 PLAN 3S I PER.M1T 11:* S NOT INCLUDE SL,OCK`WA_l.).< OF.
POOL ALL.: OTHER PC, RWIT0 REFLECT V/. KEDUCTION To PLAN CHECK
FBI? FOR M1U1.'rIPLZ ISSUANCE OF SAME P1.AN 'TYPIf:'-
TRACT CONSTRUCTION 2292.00 Sr
PORCFII.PATIC? 120.6 _RV
0-AR&OUCARFOR.T (SF) Ia,,504,30
SUB -TOTAL CC>M�' LIMON AND PLM C%IW-V.
LESS PM -PAR) r1RES
RECEIPT DATE J BY' DATE FINALED INSPECTOR
r
$3,266.20
`0.00
MUM FEE SURD MY
CONSTRUC:T1024 FEEK
101-000.4.18.000
rmoo
PLAN CHECK FEM
102=(i0() -4i39 -'f 1 LS
$162.86
MECI iE+MCAL FEE
'01 -000-421 -000
$66,50
ELECTRICAL FU
1531.040-420-400
$150.48
P'LUMDTNO FEE
101-000-419.000
$169.50
STRONG MC'. TION FEE . i2LSID
101.600-2x9.1-004
113.36
WRATt WO x'99
101-000-4213000.
520.00
DOVE LOPER IMPACT FMS
$1,907.00
SUB -TOTAL CC>M�' LIMON AND PLM C%IW-V.
LESS PM -PAR) r1RES
RECEIPT DATE J BY' DATE FINALED INSPECTOR
r
$3,266.20
`0.00
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I
Underground Ducts
Forms & Footings
_
�(� �—
Ducts
Slab Grade
(, �$
Return Air
Steel
-
Combustion Air
Roof Deck
CyF�'''—
Exhaust Fans
OX to Wrap
��
F.A.U.
Framing
Compressor
Insulation
3�r1�
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
� �>'%7%
�.
POOLS -SPAS
BLOCKWA
L APPROVALS
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
Waste Lines
_
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
L
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
(Gas)
ELECTRICA A PROVALS
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)