0206-073 (BLDG)w ",41 ..hereby affirm under penalty. of; pe4ury'that.l'am licensed under provisions of::
r } t. Chapter 9 (commencing wRh:Section 7000] of;Division 3 of the Business and
tV 1,1 i, Professionals Code, and r1'1y Ucenee is (n full force and effec4.'
p _J ch License Ai n = `tsrs''wUc<Clasa a, Exp."Date > _
? wIn
7333$3.` �� t31�01;
Z ate Signature of-`ContractorL c C4 it
f U �.• " ['� OWNER-BUILDER'DECLARATiON
' W.,,I hereby affirm under;penalty of perjurythat i am exemptfrom the ,Contractors
7License Law fol the following reason:!, ? a r'
x Z (,) . I, as owner of the 'property;,or my,employees with wages as.t4r sole
{ compensation will do the work, and the stricture is not Intended or offered for
. sale (Sec 7044,'6usiness'& Professionals'Code). E'
(�,) as•ownbf,of the'property,.am exclusively.contracting with* licensed
?•'contractors,toconstruct thetproject (Sec.`7044, Business $ Professionals
��' L,+ s ':Code) j�`hr !;;r' w �'., .+ � '{;t : Y •` 't�� .. � t � '
t< , omem;exenipt under,"Sec lo' h B&P.C. for'thls reason:
Date . Signature -of Owner• ' r K
80)tk4< ;a :(fit #a... +r. is'� ,�•� t"' y
Q `
J3-, f: WORKER'S COMPENSATION DECLARATION > -
:
V
g Z 1, hereb affirm under anal `"
0 Q Q y p ty of.perjury'one'of the following declarations:
,. I O (a)ti•I have and will maintain a certificate of consent to self -Insure for workers'
X W �-� ,compensation,'; as°provided forfiby.Sectiont3700 of the Labor Code, for the
O ;Q' • performance of the .work for which this permit is Issued.
I have and will maintain workers' compensation insurance, as required by
O U on 3700 of the Labor. Code,,for the performance of the work for which this
a �+ tpermit is Issued.` My workers' compensation insurance carrier & policy no..are:.
0�0'5 Carrier '1.d�61103� 1N1$, CO f , , Polio No. Vdf;3t10i3t83
I g (This section need not be completed ff the permit valuation is for $100.00 or less).
O 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
3, Code, I shall forthwith comply with those provisio ..
ate: Z.'Applicant_���'�`t'"
r Warning: Failure'to secure Workers'. Compensation coverage 16 unlawful and
s shall'subject an employer to criminal penalties and civil fines up to $100,000, in
1 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 hereb` ;mm de to the Director of Building and Safety f
'.
4 for a permit subject to the conditions and restrictions: set forth on hist'.
i application.
Irl Jr I. r hl Each person -upon whose behalf th(s application is'made & each person at
whose request and for whose benefit work is performed under or pursuant to
y
;,-,,any permit issued as a,result of this`-applicaton agrees to, &'shall, Indemnity
. t& hold'harmiess the City of La Quinta its officers, agents.and employees.
2' Any permit•issued as a result;oI thls,appiication becomes null and vold if
'114ork is not commenced within 180 days from date of'Issuance of such
"permit, or cessation `of work fog f 80 days Will subject permit to cancellation.
i ' •.y. is -i; x.r.. w- _,.:. >
,sl,certify that I have read this application and istate that the above Information is
{correct. I agree toxomply with :all City, and State laws relating to the;bullding
. § " 1 construction, and_ hereby._autfi6rize representatives .of this City to enter upon. K
f the above•mentioned. limpertyforrinspectlar purposes. • �'�;' ;»
3
"ignature (Owner/Agent) '� r ate'y
;�°� BUILDING PERMIT• use°M R �'
e
4 �
DATE "' + J .' VALUATION a �� ��yyyy�� LOT t f r
JOB SITE
ADDRESS l WO&A Ti G1,tW00 • 54_ a 4/11? , . ,
APN "+
OWNER f ti
CONTRACTOR / DESIGNER / ENGINEER 4t It + � F -
l?C3A i1VF t' RE81DY€N17AL HomowtWma-M
Mi7i.7t1_, MI 1V
BOAC
5080 E010 I3AU RACE #10`,
CA V22�3
8AN'DIi CA 6Axl2Z
x
(858)335.1475 CPW .5023
USE OF PERMIT
f1Bt�tAT.. BUILL7IN(i
SMSPAIC f K VIT; OLDO. .: 3, 34.649,54-654
S�l•66t+ 91•b67'. �-6'fl, S4.67�+ �.b$9
VALUATION 60600, 00 LS
Z91MWATED COOT DP CQI rff uMON
f 0,x.00
PERhaT BTU ULTAQ ARY
CONSTRUCTION RUCTION PEE 101 *000-418-000 2459.30
STRONCI MOTION VEX- RESID 101-000-241-000 $6.00
P
} .. .h -
t.
Z.
«, CC11MiR17MON AND PLAN CHEM.
$4651.50
il`3U13.1'CYl°Ai,
LESS .1'RB PAM1M
,
$0,00
. j D ST M.N DUE HOW
A4ir.
r -L.;. A1 Q111NTA
pjNpNCEDEti:
JVECEIPT
DATE {,
DATE F ALE
INSPEC
'
'
INSPECTION RECORD
'
.
OPERATION
DATE ---F—INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Fam & Footings
Ducts
stw
Combustion Air
Roof Dock
ExhaustFans
Conpww
Irmtdation
vents,
Fireplace T.O.
Fans & Contraft
Party Wag Firewd
it
Final
Finall OWAta:�: 4z
POOLS -'SPAS*
BLOCKWACL'APPROVALTS
Steel
Set Backs
Electric Bond
Foolinp
Main Drain
Bond Beam
Approval to Cover
Equipmnt Location
Underground Electric
Underground Plbg. Test
Rnal
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Unes
Heater Final
Water P1pftV
Plumbing Final
ftm*0v Top Out
Equipment Encksure
Stw%w Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Poft
Gas Test
Applarmes
Final
Final
Uft Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rwigh Wiring;
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Smoke Detectors
ToW. Use of Power
Fawd