0205-047 (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
10/02
53,3670
,pate 0 `+ k"'-' %'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:
( )
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.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.
(�1) 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 8'FA,,'tF. R>UN)D 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. ,
i f �✓ :...aApplicant '" • },.j F .'•_..X..a�..:A-:._ --.
Warning: Failure to secure Work&, s''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. s
IMPORTANT Application is hereby made'to the Director of Building and Safety .
for permit subject to the conditions and restrictions set forth on his'k
application. Y.
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 L`a 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 4o the building.;,.
construction, and hereby authorize representatives of this City to enter upon#:
the above-mentioned property for inspection purposes. 3 '
—S' nat re (Owner/Anent)
PERMIT#
BUILDING PERMIT
�,4'
DATE VALUATION tc_at9, LOT 45' TRACT 30125-1
s��
rt •'a`i,,"12JOB
SITE'
ADDRESS i�- ��i�i. COURT
APN ; 7 7.i'-vW21
OWNER
CONTRACTOR/DESIGNER/ ESN,.& IINNEER
y �,r� 2 A • y a r� �y
MafAYnolgS`1.33o.Mys, INCIJCV°
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lW:i�,�OW, 4r�+`J7�.R"V14z'L1 ON
'p�"BAAti��5lu`f�'?p•tp�pG IMT.d.Y d?�aU"�5'I3A.'C4"1'"yyi ;�i%t'.:1}{°F��. X1
CF;�"�, ',.J�sl�sV�9:�L},�� UTI.T.1:54
77.6A4,:5�A��yC
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t��J�;.i�:�I,�YfLT pTB
PA1-.11f.tdA'..cb.E�GS.1 Y�,A �9aL260
1157
USE OF PERMIT
TO
SPID ..t.4T 43 Pf,.11`N 3, - PZ1�JdI`P 37OUZ NOT FNCLUDEJ ?3I.EXI+. _V AAL LS,
1,, SPA OR I7ftI� %i1� A.I�i�Ffi,C�ACH, �� PIAN Ci�31!?CK FF%,
.RED!.i' TION I31,3'V, TO h#1 LTIPL Z XMIU. 7C2, OF S&ME F?:).&N TYPE.
f,:Sl#I'.I'OM CX034-F�`f'�.UCTION Z741,0010
PORR�HMATICi Ad,00 S
C4,t�i1.►5,0.'/C:.r`b:RPORT
PER- �lrr E`er;1513l dGfi1!a.Gily,
C»ON5TRUC TIC�1� M? '101 '0nQ«4115-00 l $11NO#,IIII
PIA14 IwliWIC f,72 101-000,439-318 $219.69
t.cp::��.�,y1y�(� 01-010-421-000 • _ $1a1,so
�VIECfL4
101-000-420-000
i�I tC'i'f9IC AI.. nS I 0 5 "'000.420-000 $25111"
PLUMBING FEY? I01.Of!(3n4•'1 �da00Q $172:x3
S^pIdK W01 MOTION FPX' • sSID. 101 -try , -241-•x`00
01W.)rA0 M.Cs 1.01.000.47 -000
1—MVE .'UPBR IMPACT FEE ' $.3,4tl5.�JQ
ART IN, I�lti UIC PLAC AS - 2.� KI 2'70.000445.000
S'[1�-'ro7`AL �'�2�d �.iJ�lV9` 014 AWL) PL./i.V G1~I:Z03:.
$4,2T7.25
IX.9 3 IRI~«'PAID , a�.9
$0100
r t' mrr 34""-8 DUE'Now
,227,
NOV
.,,, LA. C26bica'YA
RECEIPT
D'C
eY,:;+
DATEFINgLED�
INSPECTOR +;
19 —ure r ` `
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
- - Z
Ducts
_
Slab Grade
o
Return Air
Steel.
Z— —
Combustion Air
Roof Deck
2, -
Exhaust Fans
OX to Wrap
— d _
F.A.U.
Framing
_ yG-
Compressor
Insulation-
Vents
Fireplace P.L.
z
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
i Condensate Lines
Party Wall Firewall
{
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
2 - L
Heater Final
Water Piping
Plumbing Top Out
_
— � 7 �-�
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/,Z -.Z'3 - Z
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final _
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Furfures
Main Service
Sub Panels
Exterior Receptacles .
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: