0206-072 (BLDG)°j I hereby. affirm under penalty of perjury that'I am licensed under provisions of
11— F `:; Chapter 9 '(commencing.with Section 7000) of Division 3 of the Business and
W ± ' . Professionals Code; and my License is in full force and effect.
gSpF c_ Gass
License At U
7 �r:� � :.�4 r !
W r 73���/A t + �, YL aSF .EHif� •� 7JJ1�Q1
Z ate Z1� Signature of Contractor
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+gyp O
TOWNER -BUILDER DECLARATION �t t
W LU I hereby affinn under penalty'of perjury that I am exempt from the Contractor's
CL , w License Law for the following reason:
Z_ _ ( ) 1.4s owner;of the property, or my,employees with wages as their sole
compensation, hill dathe work, and the structure is not intended or offered for
sale (Sec: 7044;,4Btisiness & Professionals Code).
�" ^ (.,)• I, as, owner of the property, am exclusively contracting with licensed
=contractors°to!construct the project (Sec." 7044, Business & Professionals
►` ':, Code)
co
O I am exempt Under Section " • C B&P C for this reason
j O'N t .Date �H�ir"` }"i Signature of Owner ,
WORKER'S COMPENSATION DECLARATION
0 YZh eby affirm under penalty of�peryury'one'of the following declarations:
.Q, Q
F- O " ,
; ;; (} )?,I have and will maintain a certificate of consent to self -insure for workers'
X W u-) ccompensation;- as provided :for. by Section 3700 of the Labor Code, for the
O •J Qperformance of the work for which this permit is issued.
CO. Q`() ,f j''r ry I have and will 'maintain workers' compensation insurance, as required by
O V a Q > rr; , n 3700 of. the tabor Code; . for the performance of the work for which this
4. ;permit Is Issued. Myworkers' compensation Insurance carrier & policy no. are: .
o =) Carrier 'I. OIQN IND, CO.,! Policy No. WC31208185
r " (This section need not be completed• d the permit valuation is for $100.00 or less).
;�f° (:) I certify that in the. performance' of the`work for which this permit is issued,
r
[Shall not employ an
�;� �,• F p y y person in any mariner 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
%4"
,>1C
ode,I steal f )rthwith comply with thos!rate:Applicant '! ,�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:
t r_t a
a y
:')IMPORTANT Application is hereby made to the Director of Building and Safety
°€ ,?fora permit ' subject ;to• the conditions and restrictions set forth on his
17'apPllcation r '
r'! '1 Eachperson-upon whose behalf this'a Iication•is made & each person at
r i• PP
,
! •4 :t.whose.request and for whose benefit work is performed under or pursuant to
K. -any permit issued as a result'of this applicaton agrees to, & shall, indemnify,
i t &'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
1I r,rk *work is not commenced,wifhin `180 days from date of issuance of such
permit,orcessatlon'of work for'180 days will subject permit to cancellation,
4i .:Al certify that I have read this application and state that the above information is
'• '�' 'correct: I agree to comply with 611 City, and•State laws relating to the building
.1construction, and hereby authorize representatives of this City to enter upon
' the above-mentioned property for Inspection purposes.
t'.c�:.. •... in,..___w---.. !It'l.t1 tV/�.... �. Date�c�•�'i��i
i
bUILUING FERMI -f o mx
DATE -VALUATION y� LOT a TRACT
JUH SI I6 r
ADDRESS ; =DG. . 3 TAII; IZWOOD .5z/. &17J
AFN •_`
OWNER }
CONTRACTOR / DESIGNER / EN (NEER (,
PGA WEST RE iT7EMYa,140M3�:OWNERS
W WLI,2MERB MMM-FA'MMY CORP
P.O. BOX 1060 '
5o8o moRI`ikm FX tem #I D5`
I.A QUINTA : CA 922:53
SAN I)tF G0 CA '02122
s
(f358)5 X5.1473 CAI.#F 5023
•
USE OF PERMIT
(313TAERAL 4U..Q.I)NG
SEISMIC RETRO -FIT; BL D0.,3: 54.58% 54.589, 34.59
$4.601,254-07. 54413, 54-619, -b 3
VALUATION K00.0 L3
EbTMATEJD COST Or, OC3i1YMYICf(ON
E�,tiI3U.6)lil
'VERMIX i• FEF SUMMARY
4. .
CONSTRUCTION ME 101.0co-1.18.000 $439.50
STRONG MOTION l'rU - RLSID 101-000.241-00() $6.00
• ar
PJl3-',ro'f1�.C0NMTi:ct'CYn0N'A9D.PJ_,PlrTCTIP.(X
$465.50
' X90 PR&PAM RX,
SO -00
i OTaL1E'ERMI' VEY.6 DUE NOW
$46+..50
AUG 2 12002
- .#..
+ CITII'ORAQUINTA
�
FINANCEDEPT.
-'
RECEIPT
DATE,
@Y
INSPEC
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
F.A.U.
Framing
Compressor
Insulation
Veins -
Fireplam P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 0 0
Drywall - Int. lath
Final
Final
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
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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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
Utility Notice (Perm)
09/17/2002 01:04 7609227550 FARNSWORIH IORO
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