0112-168 (RER)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 #d�yLic'. Class Exp. Date�r
10/y i-FQ
Date / /f. ' ,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).
( ) 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.
(NJ 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:
Cartier 00J.D"4 XAt7Policy No. 44406, -024
:, d�.
(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. 9
Date: Applicant "7 P" fF,t a''., R�i�f :✓}! f�
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. -
Signature (Owner/Agent) Wit' Date
r
BUILDING PERMIT PERMIT#
(A112-168
��yy..��.r
DATE VALUATION w9 +y(,� LOT y rf TRACT ?4197-3
ADDRESS 'I9-F!)uS.T B .�.�. T A�G C y %I ,Y JOB SITE
APN 604-071-008
OWNER
CONTRACTOR/DESIGNER/EN (NEER
15:4:5 SCUJ,11 D S`.�tESTt`200
1535 30, aL° KOD
S UW --3e ,. a; CA 9208
SUM B.EIRS41D:j O CA 9240
(9fl9,'r381 `6007
USE OF PERMIT
,1nm3x,3J'1 jAL 'nmoDm.
=SlVeNTIA1:. S2.Ert.MU.DEL. LOT 39. S1UPPl,?MX;',I AJ.. TO PlE MI`!'
0.109.263. CHANGE FROM,, PlAw 5 o 1'3.,,A -AI:.( 4c"tir"ASE OF mo
S'.K 1AVls8JX 4, n'.ACF) IJUlZINO CONI STRUCi s011
TRACTCONSTRUCTION SF
mwt FT1m, wal lR�gk�7.R.,i'd.�a7i'
C'�0°9' VC` JON HIS 101..000.4.18-000 $24.5�U
a
CHECK 1100 l3 $119.99
�tii.,L�00-439-lk,+18
yyLEC
, EC A�T?:I�arriC3.lFFrI'+ 6c+�1-000101-000-120m.."000Psl $2.15A
a;R:tlN'd MOWON 1Z9 RMID 101-01V-24;
JAN 11 2002
� y•�y • .4.V_oi
`tJpLM FarKtpp AWD aJ9p, 0-WX
pq 5
6
$450
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Y` INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
02
POOLS - SPAS
BLOCKWALL
AP ROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
- 2 c _ 2
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
,„
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
JAN -6-2003 12:05 FROM:MONTICELLO 7603609389 TO:97777011
P:2/16
•
tip .--.; , �,
"• ... r>}:: :•' ;�;::,,�, `'
LA IDUINTA'
& ... ETY'D9PARTMENT
♦~`iLf
EGUEST
fON UNE
77, FL71 61
�C iIPTTi�RY.CROWELL COMMUNITIES
Own-
Contractor, rttx:rTrRv rAnwEr.i. rtjMMTT "TFe
Pwmlt Nunlbw' 0112-168
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST -SIGN ALL APP-ICABLE SPACES
JOB ADDRESS 79495•:ANDUENDIMCE-WAX
"SIDXNTI,AL RR-MODEL.:LDT-39. SUPPLRM3NTAL TO
PIRMIT 010Q-261. • CHANGE FROM FLAN S TO PLAN SX,
(INCREASE OF 17.4,5.x', LCOWS �VABL$ SI'ACX) DURING
4• .
TrvEOF.INBPECnON O.ATIE -IN- SP.
FOUNDATION 8 SETBACK p-
-
i7m7tfin IRT�ol
le
_PRE-GVNITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAG SEEN 81CINED
CONCRETE SLAB _d
JOISTS d GIRDERS
ELECTRICAL GROUND WORK d.
DO NOT POUR CONCRET9 UNTIL ALL ABOVE HAS BEEN SJONED
ROUGH ELECTRIC _^
ROUGH PLUMBING
ROUGH GAS A GAS TEST
HEATING 8 VENT -A/C
FIREPLACE
ROOF
BOND BEAM
6'K -. 'f6 WRAP
❑ 4' ❑ 8'
rrvlmlll%7
INSULATION ' ..s
PRE -ROOF
FINAL GAS
9J1Tl
HOUSE NU
/— 4lt•Z/z12
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING