0205-285 (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
7407.45 33 � "� 69130/2(
Date "07 Signature of ContractQr"'� ° �-
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.
r{) 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 ,GI] I'd CrIFIC. IN,& Policy No. 180102202
(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 rovisions of Section 3700 of the Labor
Code, I shall forthwith comply with tho e't)rpv"sions.
Date: -11-17-0 Applicantw� , -•
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 persoriat
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�for1inspestion purposes.
Signature (.Owner/Agent)Date •JZ"6-•
f ,W
BUILDING PERMIT PERMITyA�
DATE VALUATION LOT tiqTRACT' V4890-4
'traG
pv
JOB SITE .�p� q••�ep� •�,
ADDRESS 5(7 _M ff_r , ?)K0
APN yq �yry/� y,�{
1172.0 0-014
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CXUAL 1>AC3j11C HOWN" INC
C'1AP3:`rAL PACUIC HONE 1140
41 a C .�k�t 1 ��•fgl�..BLVD 02/Ov0
2 00 SYl'I�:E c d�iyt��'i�i�gJ�t DiND. #�aiK) ..'y
CC�f���0 �7 g £
NEWPORT b IGk� c,71 -.b CA. 9.6660
34
:GVH N4700IC"I S.C..�'aQ.:A'1 -j' Si.i •' ,4.CI J4i -
(949)62.2-8400
-
! TE OF PErIMIT r
3IN(YaE.FA1%&,Y DWt e 7
2A PIc�IT.., `lgiFlX f♦dN iii'1•,'r 11.e,/yP;C)i01, SPA. .
�5•�,i+��`gq7),P2..�tFy�',iy �PIX pl..gt.9�i'.eF�RL..f,��r.sK
q�0 eO(b!S
0i'S, 14I! YV,Ol4 Y Yd1�I'��.FA. J i`! Y y'idr .i T�T�"4 �1�✓i'Q i' fCy �S.t�i7.W►7�1rf� f!".1`:a'l I FJ! Qli�ma,•
§300 OP, WORK BEOU14'WI71k9OUT 7 UTLI.)YNG Pe"frr.
CUSTOM CONSTRUCTION TION 4,347,00 2P
P10P. .WP.A'1'i0 rn...ag s
0AR.a5.GR C'..: RPORT I400ZOD OF
c0wr'0- C,°ON'"r .LTC1&014
3)91,1W11.10
C0X,'TIZ';I0TION FEE I01y000-438-000 �I,42�.sti
PLMN CHECK ler 101••000-13n-318 41,01.35
7+�l�Cl�d�.k�1C.t'�,L :t�Ta: 1.01; <000A�Z 1.OfJt7 �113�.54
BL,i'i TR1CALFgfs'
I�L13,i�IIr+I�10I�'l�: 1t�2•(3iip-��i9•pt3t7 '$,�t1e�.?'�
-� _ ,.
STRUNG MOTION FEE • P2311) 101--00.0-2.41-(*0
43i1ANHO I`I;I~; 01•000-423.000 1;I�.fi4
DZY-,i3OPEIR 1:14PA .112 $ 405.00
ART IN PUBLIC :Pe. ACES -1tl STIC 270.000.445-M) X443.41
FRE DEPOSIT If.)l'-000-439-118
IN'VI?�541'IO TION RE 101'x,000-423-000 SI19331?s '
fBI MAti V0l`C.q`f:0W.(1ADPT.AN CRECK,
LE1713 XMI.-Nm 11100
47.50,00
[[''yy��pp.��q_.�� q�;��, y�7, r . r},,(+�ry�IM-777,74
•� �••p ,p
IM
PER
�1.f J.d21L1 d� .7Y1+'r1Li4 .C;:•a'.r S DA' �e .i OQ.W
7 !.7'9
JILL
i
CIWOFLAQuimu
FINANCEDEPT
RECEIPT E
BY- ;'y
DATE FINALED
INS PECTT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- cj7=c_
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
p- UZ
F.A.U.
Framing
_ (, per,
Compressor
Insulation
-' _ -�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wali Firewall
-
Exterior Lath
Drywall - Int. Lath
g o Z
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
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
Waste Lines
-
Heater Final
Water Piping
Plumbing Top Out
_ _
Plumbing Final
Equipment Enclosure
Shower Pans
0. K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Encapsulation
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring _ 6 --
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: