0109-258 (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
71418, }a1.ltl1
1;
Datet-! Signature of Contractor f ,,
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 001,�'�wtY Policy No.
(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: :c�. ��. f Applicant—
Ir.....fir? t « ^!
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 fog 180 days will subject permit to cancellatldn.
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
u 7
BUILDING PERMIT PERMIT#
01094
DATE VALUATION LOT TRACT
JOB SITE
APN
pyp e�tyrp�;Yt9�ccp�y.���p� p
ADDRESS •J"" fiSO.fAIe'+�3:��,ir.W'kbb'f'6..I�.� VVA -
��y�� .+�y (�
F:�.�'II•'072—iHd;3
OWNER
CONTRACTOR / DESIGNER/ENINEER
Vd7.LC%LVNyLVlJAyEIS
CR/WGII,CYygS
i5ils uri, FGo
1535 ',50, by8TRIyT, 3TR -1400
aM,RXRXA1:TiA40 CA 92405
SKIN'1 "WAiZ1a.010. CA 92408
(9' 09)"1.6007 C B1O 2120
USE OF PERMIT
VP „ LOT f, PLAN 301ZLV, PERMIT WES 140T INCLUDE BLOCK
XU POWSPA OR. t3lliVEW".AY APPROAM 'n% PLAN t"..`U CK FSE
R_%,r pUCT10H FORJR3UJ1XCV- OF SAIAR PLAN 9' 'X'1'',
TRACT CONOTRUCTION 1,725.00 SF
PORC'Hft'ATIO 91.00 SY,
41100M.?
COST 01r COt+d'SMUCTION
1,0 3,070.60
CONSTRUCTION Y129 103 -M10-41 8-000
PLAN N +:;HECI� FSE E 01-000-439.-3l (s
1} �'ECHAN'lCk,.4'FR , 101-000-42,1-000 fB�i1,%0
i L TR1,c;ALYZM 101-`3-4 420-000
PLUMBING FRI 10 1.000.41.1.9.000 W0100
S3TA0140MX0T1011tYFZ•M�M 101-000-241-004)
RAIJiit0 F—EE 101-000703-000 S70A
VLVRJ.,0PZR EAHPACT M1,90?:09
m,ikm t.;ivrx
$3,04.V f
OCT 0 5 2001
CIT`! OF LA V'"TA
FICi rJ,_PT.
RECEIPT
DATE
f3Y
DATE ALE/D
INSPECTOR
r
a/•t_. e — Z
I>* .
INSPECTION RECORD.
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
�`"
Slab Grade
��_l? (,�—.
Return Air - C-1�
Steel
Combustion Air
Roof Deck
,(J�, %/ 3� �>
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
— _/
Compressor
Insulation
2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
_
Fans & Controls
Party Wall Insulation
_ _
Condensate Lines
Party Wail Firewall
_ —
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
Water Piping�
_
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
�!—Z�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
(Gas)O
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
r—
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
_
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
(Perm)
HUtilityNotce