0109-274 (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
71-111163 .P _ .. rt r"1 i 0131101
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contracto `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 *he 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 t'�Llr'1:E;;'tl I''.+#1,^: iN, 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 forthwit comply with those provisions:",
rovisions
.f iAPPlicantDate: A-Z)-T;�= 9
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 �'� 4,
BUILDING PERMIT PERMIT #
DATE VALUATION LOT Orlm_.214 TRACT
�f,- 7",-� / sIfB..�,t���m 48'2'4197.3
JOB SITE, �y
ADDRESS /J u7 d17 wklf f: X d .YJIlS l•IL wAY
APN ,�!
463'Y'�Z7ln 0.67¢►
OWNER
CONTRACTOR / DESIGNER / ENGINEER
�J %krChu"�yl..�t;`k�i+:t €7(ivt l �.�.,`3
'k° T i Eb/y�+
�'!*°�jR�1c°�'�iryTifi{P� E�'I��yyCps�i����a�{3 , Cr��7M�2sg+Pt3t2�3�'�1 �++S
�(
, p
8535 90, Y hMIM', VICE, T7P2,00
ks35 b)0, ly �.i3.4�3i�ii r, U E 1M200
SAN PARMARDWO C.A. 92.0'f;4
SA14:69-R ARDWO C, 92408
USE OF PERMIT
G71Y.I�i GIJPI AM&LYDWM. NG,
Sif:) . L0T 48,1.1„ M 1.6RLV''. PERMIT 1DO,9S 140T JridG,l t}DK OLCKW.
NYALI.bNE t)O';APA QR, 1' P,PI AY A.PPROA!:fl.
Y31rDUCTIaN r0lt ISSUAX&,,E OFSAME 1'l.,AN `%YPEI:,
TRAC7 CONSTRUCTION 1,725.00 SF
PE3d1.CH/AA'1` 0 91,00 SF'
GARAQWCARPORT 410.00 OF
PrWVG,6' `FF,h1 su',odbURY
C'UHSTRUC1ION FEE 7'01.-000 -, "I 8 000 s6n�50
PLAN CHECK FEZ 101-0 0 39-318 0136.0
Ml`bCHAXICAIs SIP 10140.1€ 0.421.000 $60.00
4,3.,PVCR 1CAI, W, 101-000.420-,000 $117 7
Mt!'M81140IMB 101-000-419-000 s 614.100
S`CY.?t' NO MOTION FES 4.RWD 101.000 -000
GRANNO F:1Z* MOO
Dmulrm IMPACT nu- $t,giD7 fl0
F '
"
e OCT 05 2001. Y ow,F"E's YfVE HOW
WAYM.07
OT. LAC a: TA
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F.EtAz Cn Cr_
;RECEIPT
DATE
Bha.
DATE FV ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
16_30- O C
�� �.
_Gl
l�l�/.
.
Underground Ducts
Ducts
Return Air ——�®�_
Combustion Air
Roof Deck
/,'Z p
_
_
Exhaust Fans
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
/�.
J —/fj - 0M
% 2� aZ5
F.A.U.
Compressor
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final'
;
— •-r�
c�' S
Final
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
Water Piping
Plumbing Top Out
�c�r (Jj��
(r
f d/� -OZ
_(,r
��
Heater Final
Plumbing Final'
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
_ 2 Z
Pool Cover
Encapsulation
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)