0109-270 (SFD)V 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
7141.
Date,X,:,/ Signature of Contractor's
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 Policy No G:�586b•A
(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: 3 /A
Dater Applicant ... i' �` '
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)?-��� Date`
rr '
BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
44 7A 1.97-3
JOB SITE
ADDRESS 79�oxsyNngesmimcrLwAy
APN
-072-M
604-072-M
OWNER
CONTRACTOR/DESIGNER/EN (NEER
C I'S' tYC4�r'.I D, fi W&CUMZP.IES
4."%W(.iRY CROW E:..L COMMI liT'� £�
1535 20. T,r. 77rf?]:Ylgl M. #200
] 535 50. °D" 5MR,3 ', O.'.M, 92,,00 ..
SAN REAWARWWO CA 924013
Sisk l.1UWWARDING CA 92408
(gWy381- 007 OBihS 2120
USE OFPERMIT
0y3dr y «MyL iINVEENG
NIvU e OT44, '"LAN 5XC.':t EV, R&RW.°;ODBS NOT INCLUDE 13 LOCX
WA" PC?O.I SPA, OR DRIVEWAY APPROACH. 15% PLAN 014301K FRE
R DiYCTION FOR 183XJA14CZ OF 85,AA4E PL.A'N TYPZ
'1RAC`1' WNSTR11CP' ION 4021,00 S
POYBCEfLl ATIO 11.00 wP
aRAOEICARPORT 41.7.0013F
EMTb°IXYR COST Or. cofisrmucTron
CONSTRUCTION for— 101-(30(8..419.000
Pules MARCK ME 101-(W-439-318 $147.17
Nt��!•id�.B31:C�f�.,4r .�, 1i�1 •C3t8i8••�r� 1 •Q1,3#8 $&0.i1U
PER, 01-000-420e000 Vri-0
Pi,,rllNDMI FRI 101.000.419-IDOO '$14€.00
r,rrONt:ImfB'1 o -N ice• "11) 2511-000-241.000 "pltaj
r
GBRAD13 O V'e•E, 101_000_42$_000 $20.00
DZ'J XIDPER IMPACT FFZ $1,907.00
p q 1c y�, s'F � �y �y
• 9�1 V J. J'E,�i,�,bdi�dRi 6'►i.VJ � 2"Y,.K'v%M 4...•.�'a(±i�.
OCT 052001
1u'1�;��'1<' MIL . NaL31iW
Y OF TA
CITFIN
ANDEPTLA
RECEIPT
DATE
By
DAT9 VINALE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8• Footings
Ducts
J I.--01
Slab Grade
Z
Return Air
/ s.
Steel
Combustion Air
Roof Deck
O.K. to Wrap •
�� . per_ pS
Exhaust Fans
F.A.U.
Framing
/ .. / ....p
Compressor
Insulation
�_ pZj
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_ 0�
Drywall - Int. Lath
/ �.� 19 2 6
/
Final
Final
1�'jj p?i �� 5�
!!
POOLS -SPAS
BLOCKWALL AP- ROVALS
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
�Q3io j(�G
Heater Final
Water Piping
/ / -�y S
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
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)
_
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