0204-125 (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
73094 A W.C. 3n 1103
45
iDate{;N Signature of Contractor'����l'
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License; L'aw,;forAhe following reason:
( ) ``;;;I ;as'owne!•_of the property; or my employees with wages as their sol,e
compensatiori,willdo the work, and the structure is not intended or offered for
sale (Sec 7044,'; Bus&ness & Professionals Code).
( ) I, as owner.of _the property, am exclusively contracting with licensed
contractors 40` 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 ZURICH A+AOICAN Policy No., WCe*137W9fi-03
(This section need not be completed if the permit valuation is for $100.00 or less).
( )- I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those prove ions. — -
Date: f'55 I(YX APPlidani
Warning: Failure to secure Workers' Compensationycov ge-s unlawful,and
shall subject an employer to criminal penalties and Civil fines up to'�$I00,000; 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 orr'.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,lindqmn•.
& hold harmless, the City of La Quinta, its officers, agents and emptfldi' 2. Any permit issued as a result of this application becomes null and
work is not commenced within 180 days from date of issuance o
permit, or cessation of work for 180 days will subject'permit to Cance
I certify that I have read this application and state that the above informcorrect. I agree to comply with all City, and State laws relating to the bconstruction, and hereby authorize representatives of this -City to ente.
the above-mentioned property�for inspection purposes.
Signature (Owner/Agent) `r �=� =� + Date �
MIN
BUILDING PERMIT PERM&�v'
ays `,
DATE VALUATION . $264,UQW LOT t-� ,1 ♦ TRACT 28960
JOB ADDRESS 86--4ii o iX,IlRID_AY�
APN
OWNER -
CONTRACTOR / DESIGNER / EN &NEER
CVE@= IiO.WXi
cy-N rKK Ir 01"I.s
2280"HARDI.rOW CIRCIZ U'iJt.!'!E 150
2180.4MAIMl D.WPIRtIIJ,34 0IIT E 150
Cf3:l. fits CIA 917203
COIZO.NA CA 91"720
(9W)279-4000%si .5761
USE OF PERMIT
f TC .E Mvlz Y DVIVIL:IlU4%
SSD - LOT 44 P?.1,AN d12 119RUIT JX)ES NOi' INCLUDE 81.,TX :'WALL,,S, .
CUSTOM CONSTRUCT ION A142,003F
POW13HPA110 494.00 SF
QAAACi CA.1 PORT 689,00 SF
X MU.M COW OF CMA`YRXJC,'T10X ` �� f
1 264,284M
Pi MU Ila SqUARVURY
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CONSTRUCTION # 1.01.000-418. 1001 51 ai7.at1
P1..46M CHFIC$; F110 43'9-318
MECHANICAL ); E MIN
=i" RIC,AI,. FER, 1CY3-iltll? tl�CTM 3a�Q �,1 Yf.7
_ PLUMBING TES MOM
51R0140 Ib OTTOM FEE - USID 101. -000-241
C#k�l�liltl i 101.000.42.3.000 S2rl;att
I.NF v.A.S7"1• UC"! Uft At,' ' .2.25-00 )-443-342 MtP07.00
.ART IN PUBLIC 3 LAQ - K ale: 270-000.443.000
On- WWC-170K. AND PI"; MC3C
1X131113 F1Rk1-%'PAU>FER3
saw,
LAY e� 2f1
iTYOFLAQUIRTA ..
FINANCEDEK '
RECEIPT
DATE ,�.. +
.BY
D F �� NSPECTOR
W
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Steel
Return Air
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
o2
Vents
Fireplace P.L.
Grills l_
Fireplace T.O.
Fans & Controls _
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
FinalL
POOLS - SPAS
BLOCKWAL(APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
S , �Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connections
p ?,
Encapsulation
Gas Piping
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 i
Exterior Receptacles
G. F.I. on
Smoke Detectors Zd_
Temp. Use of Power
Final
Utility Notice (Perm)