0310-027 (SFD)U)
N
WIT',
O � M
�0LO
W
OZ�—.
6'
H�
J
Waw
U)
Z
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
,[)gate tf 0 "&Sgnature of Contra(tor-��A -�
OWNER -BUILDER DE , CLIARATION
I` {
I hereby affirm under penalty of perjury that m exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 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:
CarrierPolicy No.
(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"pr `v°isions. f
pate: f %' ! Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees..
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if f
work is not commenced within 180 days from date of issuance of such t
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is .
correct. I agree to comply with all City, and State laws relating to the building
construction, 'and hereby authorize representatives ev of this City to enter upon
the above-mentioned property for inspection purposes.
�$igriature (Q`wner/Agent) ,1 Date
PERMIT #
BUILDINGPERMIT -
DATE VALUATION LOT_ TRACT
ZWK-304.No 2.3,
JOB SITE a•
.ADDRESS
APN
g9J175..9 MIECOM THTIM
761420-4M)
OWNER
CONTRACTOR/DESIGNER/EN (NEER
V5 OPIF FOART7`1: DRS 1, I.7X ..
KAHTN .L k Comm1'x`'1' ol"r IaC
81-07o MM'C3. 3XT- v
7S-Y?0 (.:.QUIZ
TA QXfbTrA CA 92253
`f t, - i.!T k+I"I'& CA. 92.2. KS
rQiU 3b�E�4 .. Gz;I.:d�� 3337
USE OF PERMIT
Si?3 G1.Ir &'.Ah .a Y IM, _X; NT0
38. URppq7f D's��+`.r�S T tYt SAL"1S.IJ'DY, R;,L l';F:'o'6`�'si.l .%
�? - UDT a,31
�P�I.,.A
POOL. SPA 0eti.
C119Tw'M C0*311'0`xAVCT1.E)N 4.1011-0113F
i13,:iOi�fL'E>e>�tt�31$T:I, 9F
T'Mr UTM.". R S1lMMA R
C'owm3tC`:'nm 1:13? 101,-000-41C-000 $11,721,00
PLAN CHF -C.3," Fttg sixm
ft-tt PRIC:A>E.11�RT' g1•El(1f3�T C�d1�lC3 216.�J
PLdi:tfUNG FU i 01 -00105-4 9.000 11233.74
S'Tk3ONO MOTIC111 Pi -t, . i?T'S-I0 101-f1W-241-000 X40. R3
GwIr NO
k1 4'g t�PL� IMPACT r2Z $�4t3s.�►t)
ART 113 PUBLIC ?.WWZ9 - PIFISA
:fes DEPOISPIT ,101-(',00-.4,9-31 fx 41;804..00
RTB-TOTA,1:, f ONWI � 17 i`I 1 A AM `�5. MIX. •
—
771
' ).xan ?np d .I:.si'.f:w ,1'1Cyi. l.'J"e Tio o
20 200.3.
0,47
-OCT
CITY OF tSwTA
FINANC! puP'f.
RECETPT
DAT�f
BY
DATE FINALE[)
INSPECTOR
,' l
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
OX to Wrap 41
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
BLOCKWALL APPROVALS
POOLS - SPAS
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 ConnectionEncapsulation'_
.14
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 �c
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power -
Final
Utility Notice (Perm)
COMMENTS:
TW ha