0106-127 (CGAR)LICENSED CONTRACTOR DECLARATION
3 hereby affirm under penalty of perjury that I am licensed under provisions 4)
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
-7q 02 B WC UVWX
rCSate p ^ i r Signature of Contractor `26.
ki
OWNER -BUILDER DECLARA4ION
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 utider 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:
CarrieryUM Policy No. r
PT
(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: b I ; Applicant _—•—
Warning: Failure to secure Workers' 'CorMirfpensat o n 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 cf 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 propertyfor inspec 'on purposes.
n,! pp
Sig"nature (Owner/Agent)' '`va ` ��'R�''"'' uatet `�!
- BUILDING PERMIT PERMIT# u
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
784 40 Q AUX TANIT100
OWNER
CONTRACTOR/DESIGNER/EN INEER
1334 I' dKWEMAV';0240
f�S6'.11411M'=ROA
xMMEW t PMACH CA 90266
(_"A .1fED . C°1TY 'CA 92234.
(760)A,13-407.3 MLN
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CynK=d.&'LV. I ,� M cogr 01f C-1111DW 7.4.3Ciu'4 nolo
8129920
�y!p�gyrp� v�5 �y
PLAN CHECK FU '101-000-439-338 M20
M4S'!'RUCTION fty, 101-000-r 18-000
STTtOM MOTION FEE COMM 100-000.241.006' " " "S134
J
D
.
JUN 1 1 2001
A
CITY
I FINANCE DEOF LA PT
t»1 ', n1 1'1 Cf3�
$179.94:TI
Ds..
USIS ITM-PAIR-108
$U0
TMAL kii- ;1 Tr I :S DUE 11fow
9179.9'
RECEIPT
DATE
BY
D E NALED
/VJI
INSPECTOR
1
f"' �t, r,t
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
Framing �_ — O S�
Insulation
F.A.U.
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�^
Final j _Q
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
j 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
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)
COMMENTS:
Bin #
rq
�`�-�4%
City olLd Quinta
Building 8t Safety Division
P.O. Box 1504, 78-495 Calle Tampico
b Quinta, CA 92253 - (619) 777-7012
Building Permit Application and Tracking Sheet
Permit #
0100.,1
.Project Address: X79 -1¢v CA (- E ,7—A*to/ co
A. P. Number: 770-02-6) — d Il
Legal Description:
Contractor. \
Srt
'Owner's Name:.M V/��� a1 k lq—m
Address: e-
PAAY— ✓/61cJ Av .'
City, ST, Zip:,ft -T•1� OZ�
Tele hone: D
P .q
(O
3 �
1�
{ Address: tot—q-
City, ST, Zip:
2
oProjectDescription:
�Po2
Telephone: — y0 7 3
State Lic. # :
City Lic. #:
Arch., Engr., Designer: 6,<((j
r%o7-1A-o /
Address: 5:2— -1 i' -IFI'
VE-.
City, ST, Zip: S/°l /) 4D iEi906� ' 0 3
GXx.TelePhone:Y' 3•
2 3
t
S ateLi ' 7 �O
q
6L
Con structi on Type: a
Occupancy:
P nc Y•
Project ct cle one
type (circle r New Add'n Alter Repair Demo
' Name of Contact Person: _ 6X I G ry /&O/
Sq. Ft.:
# Stories:
# Units:
Telephone #;of,,Contact Person:
,Estimated Value of Project: -00 I (9
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
2
Plan Sets
Plan Check submitted
/b/a/
Item
Amount
2
Structural Coles.
Reviewed, ready for correctionsl71
Plan Check Deposit
Truss Calcs.
Called Contact Person QA
Plan Check Balance
Title 24 Calcs.
'Flans_picked-up-) fftK'Eb
6 b
Construction
Grant Deed
Plans resubmitted
Mechanical
School Fees
2"" Review, ready for correctio s/issue
d
Electrical
Subcontactor List
Called Contact Person
Plumbing
Planning Approval
Plans picked up'
S.M.I.
Pub. Wks. Appr
Plans resubmitted
Grading
H.O.A. Approval
'"' Review, ready for corrections/issue
Developer Impact Fee
Called Contact Person
I
A.I.P.P.
Date of permit issue
Total Permit Fees