0109-278 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury/hat 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
11,4188 10131/101
A�� n
Date %"' -eYr - r Signature of Contractor 3� k `a• , r"'7 A .0
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 iiisurance, 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(a%r� k12}kE8, 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: Applicant '`9 x`'ir 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 Secti6n'3706
of the Labor•Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building ani :Safety
for a permit subject to the conditions and' restrictions set forth `bk-,*•his
application. %
, r1. Each person upon whose behalf this application is made & each persoh'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 to1enter upon
the above-mentioned property for inspection purposes.
t i
P.
Signature (Owner/Agent) Dater
1
BUILDING PERMIT PERMITN
DATE VALUATION LOT TRACT
JOB SITE J
AP
ADDRESS �Q11-��°�
OWNER CONTRACTOR / DESIGNER / EN INEER
CENTURY CIRGW7xLLCOAws;O"%ftrmll MNATRYC:RO,WE- I.LCOMAIC7`k'd IT a
153 5 so. "S✓" TY E " Y, US #100 1535 80. "I3" awns 4 , oiif0
;taA.L`+� iaIMMA6:7J: NO CA 924108 M- T RERMARi INO C'A 92408
USE OF PERMIT
MOIX
SPY) . I OT 5;k PLAN :MJS EV, PUMIT ) OIEZ NOT INL1JUVE BLOCK:
WAL1.21, P001 fSPA OR DRIVEWAYAPMACH. 75% PIAN C:Hf :+; X 1'1719
31.FU)VIC'S.ION FOR, (.Sh► MICZ OF SAME PL..A14 TYPE
PORCHMA'%' O 93.00 SF
0AI24CfVVAJAP0R'9, 438,00 SF
FOID"ACED COW OF CQN.SyrRWAGN i>�',i9 >Vt.f313
i .7ASTRUCTY01.4I+"].iS 1411-000.418.000 $653,10
4L;.AII ali3=:f 't 101. CE00-4?M 1• Si V 36.00
�itMINNIC%AK, RIP. 101-000-421-1000 %60100
V,XMTRICALVRX 101 -000-420-000
:F'I.rUM13"Wo PE .' ; 101.000415-LIOO CAN
STRON01b1ti sr.IGN FEE 1?:i 510 101 -000-241,WO $10.31 ,
ORAi ING FE 101.000-423400 $20.00
t
,
ft, '.'i" ' ' , ' 7:$MA".'d"lON :OPlw�V C1 $3,6�3st.0f
�; pC� p 5 2001 AL P.MMP-°17„ S DUE H0W
RECEIPT DATE BY :� DAT IINSPECTOR
INSPECTION RECORD
OPERATION
DATE I
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings C� _�
Slab Grade'Return
Steel
Roof Deck jIJJ,�� f ��_p��®/-
O.K. to Wrap _ 9 i
Framing —% —
Insulation 1 — / .-ra`y-
Fireplace P.L.
MECHANICAL APPROVALS
Underground Ducts
-Ducts
Air
'Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
FinalT3:-
Final
.
z oa ��
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
_
•� �l Qr l
/
Heater Final
Heater
Water Piping
p 9
/ •—i���a
Plumbing Final
Plumbing Top Out
Shower Pans
_
Equipment Enclosure
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
`
Gas Test
Appliances
_
Com` j�
•Final
F
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 -j -
Utility Notice (Perm) -� -