0208-269 (BLDG)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
733152 S3 H1(; s 3�3 tJ�f3
Date A Signature of Contractor
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.Jor�his reason
Date T h 1. ; Signature of Owner /V t i, f
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.
1 have and will maintain workers' compensation insurance, as required by
S tion 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 STATE MID Policy No. 04601UN1T90994IS
S (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 3700rof the Labor
Code, I shall forthwith comply with those provisions. h J )
Date: ti . % Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawfulja
shall subject an employer to criminal penalties and civil fines up to $100,000UJ
addition to the cost of compensation, damages as provided for in Section 3,7
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 I is
Ir application.
1. Each person upon whose .',behalf this application is made & each person
whose request and fdF., ose 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 r
-work, is `notcommenced 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) ��/ • `. J Date rl j �� jfb,
BUILDING PERMIT PERMIT#
02tlfl-269
DATE VALUATION *10 W)W LOT TRACT
- - 26 02;
JOYSITE
ADDRESS. , J ; M)I �1.C��S�:�a MV001)
APN —
OWNER
CONTRACTOR / DESIGNER / EN (NEER
MA WE,3"l RFM)•..•�.T°i.3.hL AM,
I,7M.t.. AAR PAM1C C_+TiA 22_AL CON-MACP01
P.0. BOX 1060
2533 NOT)IM COAST HIGHWAY ;1M 250
LA QTTWTA CA 9225
CAM)NF EW 1W SEA CA 9200
('?fifl)t;3S�1b1f?Li1 5823
USE PERMIT
`OF
BLD0..;Af ., 5 41112,,gSi�fiAM. SEISMIC REC"ONS'rRU •! ION PER
APPRO
VALUATION MOKPO Imo!
E-s-ri'!Rd«t.'i)w COST or CrONSY;M.Mon
10110.00
1 ERAuTFkag Sf7mb'ti{ y,
C°#7taUTRUCTION P£X -. 101.000-418.000 SJ 17.00
STRONO MOTION WE- RES10 101-{40.241-000 $1,00
OF L►aU1%TA
CITY
FINANflE_OE
STIR -TOT AL comwG'1"tCtg A9.D PLAUTWX
$118.00
k
$0.00
TOTAL PEWff UZYN 1) U Le NOW
RECEIPT
DATE
BY
DATE F AL5(0 MPEC79A1� 16,
9
s
IN
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
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final � — - -
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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:/
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)