0109-254 (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.
Licensee #N b gu
Lic. Class Exp. Date
J3 f0 3
Date " /" /'/ 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). 11 .
() 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 00l,D;17,,q gC I.im TPI 1. Policy No. p -r' 4iII$eq,•9
(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: ,• Applicant ---- '1'7
Warning: Failure 11 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 and his . r
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) 41 -i h,r-1 ! /» Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOTJ6" TRACT
.1010! 70.60 4 2419'7 3
JOB SITE `-
APN �.
ADDRESS�'��.��SNi:
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C'EA'WRSP 4718 9Wa k'LT<s"OMMUN` IRS
(—IM 3°fTRY CROMLL CUA/!t'�flikmS'rais
1535 30, "DO `a3.6'RM, MU, #200
1535 30. an,I MM.I..T. MS #'Zoo
am ]BERNARDWO CA 9:408
WN b3Ei%MARi OTO • C 92408
(909)381.600.1 CI+?X:i4 2120
USE OF PERMIT
SPE) -WT T 4, Pl t7 3HIIUM PFa{::RCIT DOES NOT iNt:,IX09 01JXX
WALIA P001APA 011. DRIVEWAY APPROACH, `75% PLAN CI-MCK isle
RS 4)UCTIIO14 FOR. 19tSUA24C Z OF S tt'MFJ%A'9 TYPE
t'.i7.s!'tCT CONSTRUCTION 02100 Aril+
POrI.C4aIWA`iIO 91,00 SF
0ARAIRPIC.AXPORT 41W.09 3F
: 9MIll M Cs'o OF fWAS"1 U4a'":t' 011
1W�o-M.60
PX%wr FRE go MAURY
CONSTRUCTION N PE119 101.000-410,.000
KAR CHECK MY II �J 1-�rt1t➢-A2�£'- 1 � S.15ti.43
...,b:TRIC A!,YZE 101-000-420-000 $117. ?A
PLUMB IC FIRE 101.000.419«000 $130.00
STPOND MUM FLY& - RZOD 101-000-2,41-000 $10.31
QQ
z3EVOL0. MI lIt!fPt'l.CT FEE �9,9t37.pfr
3�
..�Cl�- '�T, G �� CFI I"'£ t'iAd.kti3£� 1�Ia k3 t��:4, C
$3,0:34.07
y yy�.�`�y p� 1[ pp�•pe- (�� �'�j�
2.�EL'1.F4. �L• ' �d' � 119 JW VE NO 9•V
13'sYj4.r 4'^SOi/!�
OCT 0 5 2001
C67lf OF LA QV tNTA
�ff.Eia�CC• L� ��F•
RECEIPT ,: -
DATE ,� ';
BY :
DAT ALED
INSPECTOR
INSPECTIOO N RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
`Q �� �J j
Underground Ducts
Forms & Footings_
Ducts
2 ^Z
Slab Grade
C) v J& U pk&-
Return Air
Steel
Combustion Air
Roof Deck i-
j=:7� p f _
Exhaust Fans
O.K. to Wrap
Framing
r0 O/ s
—�/ p�
F.A.U.
Compressor
C�
Insulation
%. p_QZ
Vents
i
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
,
Exterior Lath
Drywall - Int. Lath
^�
— g Z ��dS
Final
F�6nai0
� ��— Z
POOLS - SPAS
SLOCKWALL APPROVL` L,9
Steel
Set Backs
Electric Bond
Footings
Again Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Rn@l
Gas Piping
FLUG'u'JBHG APPROVALS
Gas Test
_
Electric Final
Waste LinessHeater
�l
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pens
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
y3— 2
Encapsulation
Gas Piping
Gas Test
r .
Appliances
Final
COMMENTS!
i34lc- 4�,.uc .s.ol
Final
Utility Notice (Gas)rte,
7-02— S
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)