0105-061 (SFD)N r r . ..
LICENSED CONTRACTOR DECLARATION
co - I hereby affirm under penalty of perjury that I am licensed under provisions of
i•;F— 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
B Inc 03441/v
Z ��C
ate;.ar Signature of ContractoF
OWNER -BUILDER DECLARATION
LU W I,hereby affirm under penalty of perjury that I am exempt from the Contractor's
a :';, "'' License Law for the following reason:
Z - rt(:.,) 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).
CV) () I am -exempt under Section B&P.C. for this reason
Lo .
r, �N 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.
Sc( ); I have and will maintain workers' compensation insurance, as required by
ion 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 ,�/gg�7�y +qy�qq ppLL���yjqq��dd}�A( Policy No.
�:�Wai�{,Cit"R A'YLIO.LiCf:{SN7� 9V OrO.YfiMNB+�'
(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:w{F,),rrr Applicant
,,Warning: Failure to secure Workers' Compensation covera� 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 Buildir
for a permit subject to the conditions and restrictions setpind(
and Safety_
on his /
application.
h
1. Each person upon whose behalf this application is made & eMon
at
whose request and for whose benefit work is performed under
r nt to
any permit issued as a result of this applicaton agrees to, & shmnify�
A'
& hold harmless the City of La Quinta, its officers, agents an
(yees.
2. Any permit issued as a result of this application becomes n
II and /oid if
work is not commenced within 180 days from date of issu
nce o
CIF
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 lii?SR-fs
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
p5ignature (Owner/Agent)"Date,<!t�at
BUILDING PERMIT PERMTH
DATE VALUATION LOTt'�,�O:aA + TRACT
JOB SITE
ADDRESS
773-=1404
OWNER
CONTRACTOR/DESIGNER/EN INEER
2%00'WAXDU) P = Z 50 -
ZZ90 WAi DLOWi.Y (MCUE, MAMIZ 150
CA 91720
CU"1:aDMA Q4 91720
(909)279.40,00 M1<0 3761
USE OF PERMIT
SYT) - LOT 71 PLAN 2A - p1at2MIT ;!" MIS NOT 'fNCLi.1DIP, 8")C:CWALL,
POOL, OR. I)M111t'WAY.&€'PROACH,16PA PL04 C.1•dFC`XRODUC°k'.ION FOR
MULTIPLE 13SUAANOE501?uAMSPl,ls11'1YP.V;
CUSTOM tv�'A STRUC'f')ON 2,A•%3m aF
POR.CHIPA,TIO 300.00 SY
4 fb1 ilri P�.4�it't�h'`P (SP)
\
y-y{{�r[�pp ,,��{�gqryry�q,.,��qy,, ,�(�{{ �(7��{ y y� yY,�V, (�►�'+'� �}p �'4�jq�gy
m4.67 7AI'ED �61OA1'b. 4�.Q' 4-•LJ.l1iYL.,l71'i.Ii✓.da'ub�'b•
,�qg /� t�/y
24BA46..V
9:�Q, ,1 ��g q�
4AR
R ,CWia6Y.%.4.y. 3L• •%S:.(C�/ �9V.YlA.IY
t t7NGTR.6S(",f1ON F R 101_000-418.000 $1,161.00
#1 C13 cr. "a 101-000-439-31 f8 $239.09
M&CHA I 11"12 101 -000.421 -WO SIMA10
. .
rA,X,,CT RW,AL = 161-.000-.4.20-000 $160.58
P?t,L$M13INO FRR 101.000-419W OO $190.95
`y1ryPul( 7111024 Fill - J;i',&IVI1'.T 1(0q, LM 11100��'�0
�Sy'i�Pryb,19 Y��6,1 @$•2y4�-83�
.�
a.J3'�-R4�i.�IX0 L'�•rY;y �'W L.+4�11'4Xe YW6)J �7.5V.6�7
1{iirRASTRUCTFIRZME 223-1000-443-242 $0,907.00
AWY 114 I UBIT.AlC: PLACE RME 701 -OW-255-000 $13047
IMP- k.)TA :.• E,t N37fIt'i C,'IiOI4' A QT1) PSI L"1 4..14:
$3,953.61
1 0 2001 x .33 M -Mo F
$0.00
OF LA OUINTA
NANCE DEPT
RECEIPT
DATE t j
BY
DATE FI
I PEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings—
Slab Grade
Steel
Roof Deck
O.K. to Wrap
�� D� ,2/L
_
8 2 tx _
6 i1al
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
—
_
_
Framing
/Q
Compressor
_E -E
Insulation
Vents
Fireplace P.L.•
Grills
_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
A
�� 6
Final
POOLS - SPAS
Final�j
BLOCKWALL
%�3�O,Z,` _ _ _
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
Gas Test
Electric Final
Waste Lines
<Vi
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
�lJ�
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 a
—
Main Service —
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors l/
Temp. Use of Power
Final V, — — - W640 Utility Notice (Perm) �—