0212-124 (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
r#1 .- y�Lic. Class Exp. Date 4,150/03
Date Signature of Contractors„' f
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 I,,)1?+f.;RTY 114UTUA1, 7 Policy No. WA7,6.21)004122,39Ir.7
(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: Applican -� ! � • _ - ----
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application -and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent t ..' Date
,
PERMIT #
BUILDING PERMIT
DATE 'VALUATION S=, -r c$ LOT t7 TRACT .70337
JOB SITE
ADDRESS _” VF0 DRYV.P. j
APN 7772: R) )10
OWNER
CONTRACTOR/DESIGNER/ENGINEER
71OU I?&C'1WIMS 19C
MUL BTC3.Tf M81 C
73=121 FR M, :�AL'lA1'G4100
73-121 TIM )WPZWG0100
PALM 1)'.�`�1W r,"A 92260
PAI -M TIR=r SCA. 92M
(760)634.9695 =4 3032
USE OF PERMIT
MIMS, F.t` WLY DN111M.,7i'C3
S3rt? • l�OT b� ;�I�C'IU'N�i �. P�1@E►til7' 31C2�'I�O�' txlL`I.Ct,t�� 131,0�:�'.' .
WAf J% POOL, SPA 09.DPNrMAY APPROACH
t "VOTOM CONSTRUCTION 218001-00 SF
PORCHiPAVO 71.5.1w sr
0AP%A0FX*Ak. P0Y4.T 410,00 2F
PRFMIT � hyUMM RV
CONMUCTION 1771KEr 101 -MO -418-000 S1,101110
PLAN r:HFIC1C FEE 101.000-439-318 1Y&W
MECHATi": AL ICELt 101-000-421-000 S 111.50
ZLECT;UCf#L VEZ 301--000-4MfTN $166.20
PI,UhllBroo FRE 10'1-000-419.000 51840
FEE - F E311) 101-0001-24)-000
,5++��'inJt■}Gt>N7CI yq�ulq,Oi;TyION
,$(23.37
V,K.SiASINO !'Chis 101-000-42,21-000 115.0
DEVf t.�OPER IMPACT YM!. $7,403.00
ART IN 1•'tTi1LIC PLACt.1- I1IMI1C 270-000 445-000 $': n
i lB- T OTAI., COH. MU'r1i109 AM 3 LA9 CHFICK
$5,005.90
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JJ �JI
JAN 0 03CI
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---_
DATE
BY
DAT FINAL
INSPECTOR
_ .�.�. _...
i
v
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
. BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
-�, . s 3 I
F.A.U.
Framing
_a
Compressor
Insulation,
o1 S-7 i
Vents
Fireplace P.L.
Grills
Fireplace T.O.
;
Fans & Controls
�—
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
. O
Drywall - Int. Lath
_ pB Z!7
i
Final
Final
POOLS - SPAS
BLOCKWAL A PROVALS
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
/� 3 I
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
?
Equipment Enclosure
Shower Pans
I
O.K. for Finish Plaster
Sewer Lateral
ZPool
Cover
Sewer Connection
iD
Encapsulation
Gas Piping
Gas Test
_ o
Appliances
Final-
-
COMMENTS:
FinalUtility
Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
_ J_
Sub Panels
Exterior Receptacles ✓
G.F.I.
_
Smoke Detectors 40,
Temp. Use of Power
Final
Utility Notice (Perm)