0109-263 (SFD)LICENSED CONTRACTOR DECLARATION
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.
License # Lic. Class Exp. Date
714188 _ 1 t +31101
Date %` - z` ' >' 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.
( ) 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 ,.Cvia+1.17rhi 11.i3T.�� ltd: Policy No. 2+8iA�C,•� 11081: �3
(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,
1 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:s� a Applicant ��-'%�"•='`z � � l�,^ �
V.�, / ..r,,
Warning Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to 3100,000, 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)" I r x� r +°'%� j c Date `L
BUILDING PERMIT PERMTk
DATE VALUATION LOT 0109-'21115.5 TRACT
r��7 ry
PurJ"vY\JV 147 24197•'3
�fA_ e•"'-. n f
JOB SITE "
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
CWTUR R Y CMCi'WELL COMMON"I.1Y
C 41TURY C;RC9 WELL C0_7 Fd!<'i1.U1Tf '9e,1,J
1335 . 0 r ,5IRH1' K. MI[ e., 47,ti0
1535 30, S" 31RIMr, =M. #200
(909)381.600'? af3 #. 2120
USE OF PERMIT
01012 FAAWly
SIM - LOT _?7, PL AU4 2A. PULKIT DO��'.,'� NOT MCL UDE 131X)t;iC ''AL1 `4
s OOTAPA OR D}Y,SV ERWAYAi'1''Ep.,OACH. 73% PLAN CHECK FH PEDUCTION
MMETH.` �AVIC,E OF ;s.kME PLAN T YPL:
TRACT CUN3°f,RklCVON S
POkCWPATIO STIP
cAi3 A S3f �4AJY%°OE"> 412.0 0 9F
`ln'Urm COST (NI, C C)Jtci:i'.M0a170.K
.30
'1'1 1"ff'u S'I K A.32y
00M'I'REfj�:;'1aN RM 3011 000.418-000 S5900
PLAN' C1,19CKPrIN *1.24.56
M1vMt:3,NICAL'N'RE 101-000-421-000 W.5
1~'1 IRC1'Ms; ALFFM 101-000-42,03 000
P1.,UVABINO FFZ 10141004.19.000
STM40 MOTION Ir°F Z • it iFv. 3D 101-000-241.000 $9,99
ORAD.WO PER 101.000423.000 $10.00
I7,EV L.OPER. Y1tAp.,f CT "Xl,907.I?U"
Mffi-TafAL CONTbIr ZUC11014 AWD PLAN I fad'
$7,j947.19
k.17SS PRFJ.3.AJD�7
11 T.. Lt:reA''W9 S DVE Now
tJ
i'J'di Iail,+"
OCT 05 2001
CITY OF LA QUINTA
FINANCE S—PT.
.
RECEIPT -DATE
BY» A
DATE 51NALEV
INSPECTOR
71h
:� r
INSPECTION �EC;C��RC�
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
Forms & Footings
APPROVALS
�D 'Ur! ��
i
MECHANICAL APPROVALS
Underground Ducts
Ducts —7-2
Slab Grade
Return Air
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
O 3sD/
/9_e -W
_
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
_ _
Fans 8 Controls
Condensate Lines
_ _ _
Party Wall Insulation
_
Party Wail Firewall
Exterior Lath
Drywall -Int. Lath
..
Final
— /?— L
Final
P®OLS - SPA5
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
PLUM BIMG APPROVALS
_
Waste Lines �U//�f��
Water Piping �_ _a, G
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Shower Pans
Seaver Lateral
®(/�
�
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Sewer Connection
— a _
Encapsulation
Gas Piping
_Z
Gas Test
Appliances
Final
COMMENTS:
Final .7
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)