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0109-255 (SFD)
LICENSED CONTRACTOR DECLARATION I hereby affirm under. penalty of perjury that I am licensed un. 'r provisions of Chapter 9 (commencing with Section 7000) of Division 3 of thE,'usiness and Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Dai., 1 714168 U _ 7 1101 s ^ 41 Date 122- 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 t I �5, Policy No. IfW,',,'-344ft#,(Y4 (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, If shall forthwith comply with those provisions.. Date: t/,' 4 :1 Applicant `,.r 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 aoK, his application. r 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. � r Signature (Owner/Agent) } - •<S / l-•� '" Date' BUILDING PERMIT PERMIT# TRACT DATE VALUATION LOT TRACT JOB SITEy�v.�yry�yy�e�y/�y,y�yP ADDRESS I�" • •`r!h�/ +ti ,'G..`dLY.l:at•L�i> . Wpy�A APN 60"724VS OWNER CONTRACTOR / DESIGNER / ENGINEER C",1.+'1dTT URY C:ROVIEL . CaC71&Ai3N1'1��,E.•1�' (12NI URT CROW :E L Mladllm lkm 1535 ao, spa mmza, Sn".10200 1535 so, -V �`.t'1�1+.gnu I, ftoo ` - vAM E k�A3`.A�`� 010 CSA. 92408 sAM BMNARDW 3 CA. '3-9 t8 (909)381-6007 +C'x` lA 2120 USE OF PERMIT 0WapMwVry/5 1 / trr) + I.f37.' P f 3kFl. PLi'EW.3T VC)F: ", NtJT I<WrL6• DE BLdJCK'y4.tk,l LS, s��.1l�C.jy.p�+':'�y�.P:�c��p.•��(�.9O�R}Wy�ipR♦gf'/� H, 15% PLAN �'ii�',CK PREP RIMUC 'ION �m.�{,}4iy�A}��'y��+��.�J.+�(�C S OR..t9%�11dJ'11910E lJ.\' i��F7iiVNZ F',CYx�,Y�' iS�Y.l' X TRACT CONSTRUCTION 2101100 OF PORCiidBATIO b,.?.00 SF QARAO i ARPC3RT 41710D 3F cors OF CoONSIRiTMI,GH 118,Us a0 gg}},��VV++��yy77���qq•�yy �.y���yy �yg� y `per gWro"'J." .S.i'r.["4iW'b•�•�• .SJ ,IDri1iuY 6JR.1M:W4CA�1 4:itt�P°Yf1� ilw�41�i�f X6.00 PW, I CK,MC K RE 101-000.4:39-319 $147.17 Ni13,CH.1A[CAL Y- F8 101-000-421-000 S60.00 '91.,V-011ZICAL ftZ 10t000 -42a-000 SIV. -59 PLIUMBIN In PE. K .101-M-419-000 $148.00 ST? ''t_ZLF M07101; wiPp .. Ta�eg.wa t Al n00.^.=gA.1 00u $ii.�►f - l'� � ►t8(�Q�23�(�flfl ���yy�?g1l�►y Yx.�,l�d.�dt»� �p yet �+�pp� �p ,P� YeA�eS. 11FIR SYI:C'.d'illF FP.:'N l (n��FY }'. WN R ;} BUD yya.WAL CC1MU3011110 4 V I D FLAW -WX.K $1,121.56 - LESS• PRE -MD r. 1,11 $,Ijo • �� � 1L t,+'��.. �X.�.1;' �~d'i..�''R�' .87 �.R� d'!•�A� k�7a.5 �i'� �:'� OCT 0- 2001 C[�yy OF LA, TA': RECEIPT DATE KI�L.L "� "Y (� BYpp� r DATE F NALED J� 2 INSPECTOR INSPECTION RECORD OPERATION ®ATE I INSPECTOR OPERATION DATE I INSPECTOR MLMHO APPROVALS My ECHQMMAL APPROVALS Set Backs Forms & Footings Slab Grade /U Z- ( �G • 3 U=U( — - Underground Ducts Ducts Return ,sir Combustion Air '1 Steel Roof Deck Exhaust Fans _ O.K. to Wrap Framing Insulationp IZ..`_�D_ �, .�,- � i f�DZ - ©� — F.A.U. Compressor Vents Fireplace P.L. Grills Fireplace T.O. Party Wail Insulation _ _ Fans & Controls Condensate Lines Party Wail Firewall Exterior Lath Drywall - Int. Lath °>Q4nag Final POOLS -SPAS o LOC KWAL L GaG° PROVALS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test F6waig Gas Piping PLUMM0 HO APPROVALS Waste Lines �0�� Water Piping Plumbing lop Outts Gas Test Electric Final Heater Final Plumbing Final Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Sewer Connection �— 2,3 —Z _ Pool Cover Encapsulation Gas Piping Gas Test Appliances FBnaO COR Mi/ ENTSs g5z4, W-41/ S .oE m� P (FOroaO UU14 Notice (Gas) —_ —Z ELECTt MCALF APPROVALS 'temp. Power Pole Underground Conduit Rough Wiring Jaf�v/ Lova Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm)