0301-330 (BLDG)LIUEN5EU WN I HAL; I UK UhGLAHAI IUN
I her zffirm under penalty of perjury that I am licensed under provisions of
HChat (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp. Date
LU D MCI 31.11 A)3
t-
oZ r— Date Signature of Contractor
co 0' "i
J U 0 OWNER -BUILDER DECLARATION
HWd r__I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
6e) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Busines & Professionals
Code). _
() I am exempt under Section B&PSC' &ri is Eason
LO
N Date 1 >> Signature of Owr'i8ft� -`
ON
0
CL'Q WORKER'S COMPENSATION DECLARATION
o cc I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL- compensation, as provided for by Section 3700 of the Labor. Code, for the
O � Q performance of the work for which this permit is issued.
C0 Q I have and will maintain workers' compensation insurance, as required by
p 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STA.,TF FUND Policy No.' 0460JVN]°s'(1tlit9413
Cb0
g (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, anVa ree that if I should become
3 subject to the workers' compensation provisioSection 3700 of the Labor
'Code, I shall forthwith comply with those, provisJ
Date: Applicant „' J
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 repr �IS ntatives of this City to"enter upon
the above-mentioned property ('o'r,inspe 41 n p, rposes.
Signature (Owner/Agent)14 �-7 Date! -4 '
BUILDING PERMIT PERMIT!/
1 0M3.--330
DATE iiQ VALUATIONSIOMLOT ' TRACT
JOB SITE
ADDRESS S'31.iil'G, 33 c.�i�.�10145 -.R.TVY . 4 � Q - %a
APN
OWNER
CONTRACTOR/[ / ENGINEER
MA WZY RE'>Mii:AF INL. ASSOC, I14C°
1)]EL 1AAR €1JkV,iF'T(.' GG,:13'KRM,. Ct ;) ).'zxAACf(Ji
:P, 0: BOX ] MY
25 313 SGUTIT MAW 1UGI'CWAYXf'1= 210
IA,?'(WfA CA 92253
C;.ARD.U..+ JAY 170", SEA CA 9200?
-
USE OF PERMIT -
SL1:#Lt 33::*se1 4 -A-964,54-956,34-949. 'V 0I,1 l'TARY
STRUO'rul:AL McaDIFTATIONS
VAIAJAMIN 1.3
E9TIMA17T) COST OF (31(D WrRUM'IOI4
.4C►E}E}.'}U
PTrR1VMFEE SITiV/IMAR
C011111TRUC"P ON RE,
S"Fflf ANO MOT1014 VEX -. RXIF3113 101-000-241-000
FEB 0 3 200i r
v
CITY OF LA QUINT �
FINANCE DEPT.
A
�j[9T3 1'C?'!'k, >'.�'C)�J�3`1`Xiitr fix A:Nv' ITAti CHECK�
'C1rA:.I'I+�T?I]V37iT:rIMS LAMP NOW
$:154,4}
RECEIPT
DATE/,
B w.- _.
D E FI ALED
INSPE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
i
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. 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 d3
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
al
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Fina!
Waste Lines
_
Final
_
Water Piping
_Heater
Plumbing Final
--
Plumbing Top Out _
Shower pans
Equipment Enclosure
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
--�
-
Sewer Connection
— _
Encapsulation
Gas Piping
Gas Test
--
Appliances
Final
i
--� _ -- --
COMMENT
(j� 7 1�p3A
Final t
UtiliPv Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power"Cote
Undergrourid-Conduit
Rough Nihng
Low Voltage Wiring
Fixtures -
Main Service
I Sub Panels
Exterior Receptacles
�F.1.
I
_
.oke Detectors
I
_
emp. Use of Power
Final
Utility Notice (Perm)