0103-048 (CP)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
°•
c„D e590377 - (x753 C2 C .J /�,, -,1 30 h4 '
"' I_171' y Signature of Contractor �. +�.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor'
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 avid 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
Sddon 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 Policy No.
STATU FIRM 220-00 U141T 0020130
(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, Ishall,forthwith comply with thioselprovisions. +' '
Date:-�:iWA4, Applicant °�-_Ig 1 a -
f4_ ,A�,..
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 tlie;L'abor 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) �'"=-I�' $ '•^ !�j kltlZIADate
V
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0103..048 TRACT
JOB SITE
ADDRESS
APN
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' CY�14DII S IY.A:T.6l.�il.Ui9COC db dCd. i"S
..
OWNER
CONTRACTOR / DESIGNER / EN INEER
� )UT° ,t°'1;"t�' IMIL 3 I)EIMC3MEN7'
't3Ni'MAL.FOTH=
55-161 Souk .ntmu"s,DRIVF,
73-9W kIIXGHWAY" 117, UUM8 5
to Qj 72d1A CA 922.33
PALM IMERT CA 92260
(760)568.6726 MLO 5220
USE OF PERMIT
PCG L ANVOR SPT,.
WATER FrATURE.AT SUMMIT PDX YW}jS'T 1iN'd'RY• INS► tt"i'IOIATION PEA
A:d PLIED FOR WORK 9TAId.TRD MOR TO ISSUANCE OF PZRMIT
POOL ANDIOi SFA. w'"P.09wq
"
Y4GMA^. M C O S7 OF 'C,'0X57To`1 cTf 0Z4
7,0WM
a' ft i F WAM Al
PLAW 01RCK FEE 101-000,439-318 sial �0
CONSTRUCTION 5VIE 701-0010-418-000 sgo.ria
MUCROWAIL. FRE •- Pool, 101 -000421-000 $24,00
EL riA^ITUI CAL FEM -- POOL 101 -OW -420-000 $45.60
Fdt«fllwli? NO;# FKZ P0IZ`, 101-000,41 "00 =00
Iwrvi1'.mt3'I"ION nw O r 101.000-423-000
MAR 0 7 2001.
SAM -TOTAL +t:l'32dWfl.'IT "1'ON Pit�`T7L PI—A4'+ly���:iENK
S334.5•0
f t �
EW
77KAL.7 "MM FM D NOW
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel J _
Set Backs
Footings
_
�j1i� p
Electric Bond
Main Drain
Bond Beam
7j ��_
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:
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)
Bin # ®�
� City 0fLa QyInta, .
nJ'A
V-(���"Building 8T Safety Division
it #
P.O. Box 1504, 78-495 Calle Tam b
La Quinta, CA 92253 - (6 -701
I
Building Permit Applic on and Tracking Sheet
Project Address:/J,L, Crj gft_e'sName: •�I
_v_
A. P. Number: H Address: 71M
Legal Description: , ST, Zip: ; 1
Contractor:Telephone:
Address: .Q S roJect escription:
City, ST, Zip: 4Y &5; "
Telephone: t '
State Lic. # : (+I City Lic. #:, J ;
Arch., Engr., Designer: 0 t �/ �i•-
Address: V. ® she)
City, ST, Zip: YCAO�L S' 5
Telephone: el hone: '� Construction Type: nc
P 6 Occu a
�. D P Y
. a (circ nProJect hPState ic. #: lee) e Addn Alter Repairair Demomo,
Name of Contact Person: ; ,. Sq. Ft.: # Stories: '# Units:
Telephone # of Contact Person: l �i • �p Estimated Value of Project: cm
APPLICANT: DO NOT WRITE BELOW THIS LINE.
#
Submittal
Req'd
Recd
TRACKING PERMIT FEES
Plan Sets
Plan Check submitted
? Item °
Amount
Structural Calcs.
Reviewed, ready, for corrections
H2 Q Plan Check Deposit
Truss Calcs.
Called Contact Person JU
0/0-A q Plan Check Balance
Title 24 Calcs.
Plans picked up
w, Construction
Grant Deed
Plans resubmitted
Mechanical
School Fees
2nd Review, /issue
3Tlllo lectrical
Subcontactor List
Called Contact Person
�j ��' Plumbing
Planning Approval
s•
Plans picked up
S.M.I.
+
Pub. Wks. Appr
Plans res
Grading
,
H.O.A. Approval
3d Review, ready for corrections/issue
Developer Impact Fee
"ontact
Person r
A.I.P.P. '
Date of permit issue
S/7/61
Total Permit Fees
t