0205-046 (SFD)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
<t.3si4i7fJ k'. i V30/0
,Date /"� ;? ; �'. -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.0 ' 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:
Carrier .STATE MD Policy No. 0715.2
(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: r, A-. ,n -/-APPlicant�'� 11) t..
u•,�
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
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
bi
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. f
Si nature (Owner/A ent) � � -�`�* -- Date t • /..-. — � i':•.:
BUILDING PERMIT PERMIT#
02€I51"iii
DATE VALUATION S226'50LOT 42TRACT 3012511
JOB SITE'
ADDRESS �°ki.N=
APN
773 .2 -021
OWNER
CONTRACTOR/DESIGNER/EN (NEER
DO A ;r7O2 EA, INC
SUNdtt SIR ! OR31 ?"T101..4
77.554 CCT017't"1�Y CLUBURNrE ff ME 137
'77 -64 iA COUNIRY CUUB;t 17M, MT72 3.50
P.AT.,IkTI! ESEW CA - 92211
1. 2AI..M:£?h�`'1�RT CA 92260
(760`772.8714 CMS i IT?
USE OF PERMIT
0WOLE FAMILY iJWF 'ft17C1"
Vf) ,, WT 42 PLAN 3R. PERM;T DOES n1:OT IldCLUOR 131.K:XX W Ai..LA
POOLSPA OfI DWWWAY APPROACH. 60A0L AN CHFC'K FFZ
Ia DUC;' ION r)UF TO M.U111P A ISSUANCE OF SAI IF, MAN T` PL
CUSTOM CONSTRUCTION 2,74'1,00 SF
PORC;HIRWrio 21.6.e0, of
C.1.�1.F:AC$1PlC'F'�R �I;`d t1810 OF
9filllmWIN 9 COW OF CONSTd'iMarioN
2245*.r.A9
.PEMT M 49UMMAVY
CONSTRUCTION RR 101-1000-418.000 $110"too
PIAN CHFZX I'7PZ 101-000.439113813 1310,69
MECHANICAL FE 101-000-421-000 $1442.50
cKiltr- 191C.9.I..1fUN 101-000.420.-ODO $1390
X#I,.UMBYHO ng 101.000-419.000 $Mo2s
ST'R'ONG MOTION ." m Fd -011,) .101-000-241-000 $712.63
(TRADING VTZ 101.00014423-000 W100
0_WV 1PZR IMPACT FEE 00
ART W PUBLIC PLA�''•i�`� - USE 270.000.4445.000 �65.3ti
2:t1C1709 AND 3,i.,AX CHECK
$4,227.25
L09 PrNS-PAM fERS
el �c5r
$0.00
FJ 'FTE115 DUE Now
$4,2-3745
CIY`f
P1td0•°�C�
RECEIPT
DATE ,..M1j.BY
^..
DATE FINALED
INSPECTO /
9fir,, r{y-•,:,, ^- ,
..�C.,- �! • � � .r: = '?�•.'� 3 � i gas. i<a
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
2_
Ducts
Slab Grade
,/O— 3
Return Air
Steel
Combustion Air
Roof Deck
- /g —
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_ J
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
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 Connection
-� _ 2 ,
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)