0109-253 (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
71413 10,03110
Date �� 't �> / Signature of Contractorr.�'"�
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 t3C,1,D&4 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: �� �'•y Applicant
e at''w3Pr, �+�d�.
:.., ,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT. Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at.
whose request and, for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta; its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is, not commenced within 180 days;• from date of issuance of such .
permit, or cessation of work for 180 days will -;subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating.to the building
construction, and hereby authorize representatives of this City to enter upon .4
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) s/�•i + . �t Date -
r
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
24197-3
JOB SITE
APN !
ADDRESS - o I?:MP11 ENC,IF WA'Id,
104-072-M,
OWNER
CONTRACTOR/DESIGNER/EN (NEER
4:tE,WURlC C.=�t.{5VIM.1. Comm €7Ar iTm
tID3'1'UIZI, CR10w0j(11alowlMnla
1535 S0.O° OidR] «F., spI., 0. CIO
i 53J U01 `v unuwl MM�Ct
VAN BY"AR 3WO (:.iA 92.4C?t3
SA.fi3 ; FRUARt INO CA 97AO8
(909)381.60M ¢60M 120
USE OF PERMIT
.-PP -1 ;&)Y':{ ,1PLAN 5 C. Ptv:RMIT'DOE3 NOT ahfCt UDA HLOC'KWAi..VN
POOLoft OR DRIVEWAY API ROfiXII,
TRACT CONSTRUCTION 2021. Do SIS
Pd)RC'.HIPATIO 11.00 SP
CfrFa3liiTtl4"�lc'f;�T3'I` 4170 SL',
I;'F2ur5' bwx SUMMARY
PIE DEPOSIT i�Ypi1C9i�-�?�-"13� •�^�tl,�(�
CO"Nu'd`'RUCTIO3 V11213i1k-�3(lif-$I -�QC1 "+i06.Qf1
VN1.H AH ICAL F9 Z 101-0004 21-000 $60.00
PLECTRId AL MR 101.000.420.000 $12738
sPLt3NIKHO?VIM tot -00.0-419 00 S148.00
eI''f,,oIdo MOV014 FEB w I!YMID 101-000-241' - M% 911:51
itRfi-1,'?XCS L 101-000423-000 S29.99
DEVJ?I 0PER IMPACT FEE
�- LESS PRE -PAX) PUBS
-v750,00
PYJ.0M'r# ESS DUE N OW
OCT 0 2001
Cj , OF LA_ n_u INTA
RECEIPT
DAnnT1AE t}'
BY ff r
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
�- CJI
(ji_�(� f
Q -Ya 67 ( _
Underground Ducts
Ducts
Return Air
Steel
Roof DeckJc�47/
O.K. to Wrap
�� 2 > Q /
Combustion Air
Exhaust Fans
F.A.U.
Framing
_�r�_®�j
Compressor
Insulation
Vents
r/E
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
_ _
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS 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
_
Waste Lines i
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Aa
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connectiony
—� Tj— Z
Pool Cover
Encapsulation
Final
Gas Piping
Gas Test! i
Appliances
COMMENTS: B4tt'�t�s•oc y„s�,s ®�, :d(�
-
-
Final
Utility Notice (Gas) ,r—
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring y ,�
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
_
Exterior Receptacles
G.F.I. -- — —
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) ~ —/,�z — Z