0301-333 (BLDG)LK;tN,tU I;UN I MAI; I UK UtI;LAMA I IUN
I herr' affirm under penalty of perjury that I am licensed under provisions of
Chak, (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
r;3;"3152 N w 03/11/2(
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).
('•., ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section B&P.C�fgr thisreason
Date ? ` Signature of Owner ► G
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 ?7 �4'i d! K11.11) Policy No. 04001 kilWT0009414
(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 pro, I' ions.
Date: ; Applicant—
Warning:
pplicant 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 foQ�nspectjbn purposes.
Signature (Owner/Agent) — Date
BUILDING PERMIT PERMIT#
�1
®
DATE TRACT
1 VALUATION LOT
f
JOB SITE
ADDRESS '01.1110.36 C.11AMPIONS ..RTV,Cit RA .5-4- q 00
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER
PGA WM 1 D1NF1 IAL., AfiW,''., WO
DEL MAR. P.ACW-W t3r.1 YRAL CONTRACT' �I
P,C).13 rA 1060
SSC)
LA t.11brrA CA 42253
CARDIFF BY 1111K SEA CA 92007
(760)E35r1010 (,'""ut ft 5823
USE OF PERMIT
4iLaal,Ii=.'RAI T3ly.1f.L571J�3
13IA)0.:36. 54.900, %900, 34.992. V'0L'UNTA RY :S'rRUE'TUP.A.t,
lu40U1MAT1ONS
VA 01AI'1'1C44 1%*0 00 t -114
Pll' MU FFE SUMMARY
C`014Mtl(".HON YY -K 101-0150.418.000 5126.00
S`t'RCMU MOV074 FEE. e2MD 101-0013-24.9.1100
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RECEIPT
DATE
BY-�
FI LED
INSPffr
e
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
i BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings •
Ducts
Slab Grade
Return Air
_
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
-��
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—'--��--—�
—L— —
---�
J POOLS - SPAS
BLOCKWALL APPROVALS
_
steel _
Set Backs
Footings—
Electnc_Bond
Main Drain
'
Bond Beam
--
y~_
i Approva9 to Co°ger
Equipment Location
I
---- -� —
_ v
—_
Underground Electric —
Underground Plbg. Test
---
ai I
PLUMBING APPROVALS
Waste Lines (
I Gas Piping
Gas Test
Electric Final
Heater Final
I
Water Piping _
Plumbing Top Out —j _ _—_
Shawer Pans , —
Plumbing Fina`
Equipment Enclosure--
J.K. Fogy Finish Plaster
' Sewer Lateral --i .
aewer Connection+. ---� —
_
Pool Covpr
Encapsulat,a� -- — - — r
---~--
Gas Piping
-- —L --- -
-- ----- --- `� — —__
Final—. — ----- —i
Gas Test
Appliances
-�
_---} --
COMMENTS:
Final — ---
LINO\ Nofte ;Gas)
—
o 4.11.1elt
ELECTRICAL APPROVALS
Temp. Power Pole
3
Underground Conduit _
Rough Wiring
I
j
Low Voltage Wiring — --" _—
' Fixtures
Wain Service
Service
Sub Panels
Exterior Receptacles
dke Detectors
erfip. Use o1 Power
Final
Utility Notice (Perm) — -�V—