0210-071 (SFD)KIM
LICENSED CONTRACTOR DECLARATION,: 1
I' hereby affirm under penalty of perjury that l 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. t.
License # Lic. Class',, t Exp. Date
7•
Date Aa 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).
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 STATE FUND Policy No. 1640462-01
(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: •z 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. 1 s
Signature (Owner/Agent)��"� Y. Date %�a - !'^• - =�
Y�
BUILDING PERMIT PERMIT
21 0-0111
DATE/ VALUATION s:k�4�yry e� n) LOT . TRACT y 1 +!
4 �!t tfll+rfi� 1�i :i'8a~{i.7•y
JOB
ADDRESS 7'7-760 CC?NCRA CGU ' -
APN
OWNER, a }�
CONTRACTOR /DESIGNER / EN (NEER
-�
sw 014.A, Homns, wc
SUMOMWO'F:MIO
r 7-564 COUl!'I`1iYI U laRM IRYM? 137
77-645A, C Ot3NTRY -Cr UB .1:�� IVE FOi i� l50
PALM DESP.RT CA 92211
'P,fi�S.ls!1IID2KWAIT CA 92260
C -160)772n8224 %r133 P 1137
,
USE OF PERMIT
ISM) .1,01. 10, P1,414 Z. PE1t1t41'f'•1:10-ES'NOT VXlr, 1,UDit i''.'>1.XACr,
WA.TAA% POOL, 81PA Oft DPWF"WlAY APP1iOACrH, 7g% REDUCI T 10V TO
PLAN Cl*!CIK FEE DUE TO 1.4ULriPLE ISSU,,ANCZ OFSAME E'LAU TY. VZ,
CUSTOM CO1Vb l'4 iikITIO`N Z4KD0 ;•F
123.00 SF'
QAIA iMMARPORT 663>00 14F
lesIrMAMPM cosi OF Co.1'4s"Iwc;:Cfon
207,822.70
F.M. `[': F. b13'.t oYs IZY
CONSTRUCTION TION FEE 301-000-418-000 s1,91'iso
FLAW CiIF..t K FEL 101-.000-439-318 W..3S
MECMAEalttAL FER 101-000-421-000 00-421.000 $108,00
E.UX TRICA L FEES. 101-000.420.000 $133..Cm
PLt.FMF1INO FV? 101.0100.419&000 L165100
ST1!10 N0It9fsTI01ti 11'sF: Y TLt;'a1D 101-OOD-241-000 $2WAS
OTiAX)INOIV,' 1' 01.041i74`ZO4- 00 WIWI
OWEIDPER JUPACT ;F-9 $1,403,0D
ART IN PUi3l, C it.1�'XE S - RLT11,27Q-000-445-000 3*20100
dO1tififIRUCTION f#l+lly:[;{�I.Ayt+,tpO�`gil�4,pt,i K
$4,093.9
9
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W13119
0%T 1 2002 �;Ijl2iI
RECEIPT
DATE -""' " 8Y 4,�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
— -
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
2 -Jz
F.A.U.
Framing
_2
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
—.z
Drywall - Int. Lath
2 - 2 5—
Final - 5
Final
— — 3
POOLS - SPAS
BLOCKWALL
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
Electric Final
Waste Lines
Heater Final
_
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
'Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final _ _
Utility Notice (Gas) Eli
ELECTRICAL APPROVALS
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
I&E
Utility Notice (Perm)