0205-028 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that l 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
1.33670 6 43 0/0 2
Date 4J/a%I /s •'>-" Si nature of Contractor ` " s'`' o 1
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.C. for this reason
Date Signature of Owner
a
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) 1 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 %IIS Policy No. 6"/152
'(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, l shall forthwith comply with 66 q provisions.
Warning:'Failure to secure Workers''Compensatfon 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 thela6prCode, 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 perrhit;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 cessati6n 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 representative's 'of this City to enter upon
the above-mentioned property^for• inspection purposes t
t
�r'Signature (Owner/Agent). .r ov�-_.
-BUILDING PERMIT. PERMITk �'• "
.010..jp�p.o
LOT i TRACT
DATE VALUATION $22 -=U 1 U»1
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
iol'T ..T30I ms, Ble,,
;awma COl:2PoRkuom
77-564 CpURCRY MFUB B 13'1''1'
�C 6 . �,(t�x t� f �'f : L,t1i'• i v"L 1"ks 150
PALL +:S�.�Y s�l� a22 2
P. UA,_MMRT CA 92^460
(760)772•S2201 011,14 •3.137
USE OF PERMIT -
,xMO L,FAW✓YMSITIM0
SK' a i 1 PnKN ryPE-R&MT DOESNO yNILUDE UAX WA1,L.%
11001., OA`M. DRIV .W.&Y APPROACH . _
CUSTOM C'O>OT12U TI614 :4629m Vit}
PORCH1` AT10 216.00 SP
GARA43lfil+;✓`ARFORT 613(t.00 8F
dbm"M ?.n`o8y.&• O)r 4a'CXmmu•�..�4,�.o
..212 aa0d900
-
CONSTRUCTION FEZ 101-000.418-000 SJ100100
PIAN CHECK ME 101-ow4 •�'-•318 X6$.26
MECHANICAL FER IOI:aCfUO=�2.1•C541iI $1G?•
41 12.
IEL✓•W rAL Imo:< • 101 -000-4201000 ffi 13�. 12.
Pi.,13MBIND FEE 101 _000-419.000 $172.25
eTi20140 MOT101419 E ItI?WD 101-000-241-000 MOO
G'RslDINO FEE $15400
17I;51•EfZIAF.•1-1 J.MPA XT PFX- $B,40&00
= •-
ART IN PUBLIC PI,1' M ^ RUI12"10-O 3 4;5.000
SU - 3•C'.r'3'AL C~ONAIT.WYCYTiOR A1:+ D Pl.. W C.ITC+; W
$A,831..1 S
LESS PRE -PAID M93g
fit;i1+O
r
�o.4.��0:�4�
AM
S.tbS!.5,4.PrS437.`S'4�.71.:.V4JOY+'Y
tN"3
OCT 0 4 Z002
CITY OF LA QUINTA
F1
RECEIPT
BY; j �'f
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- 2
Underground Ducts
Forms & Footings
p --
Ducts
Slab Grade
p s
Return Air CIA
Steel
—y .
Combustion Air
Roof Deck
d -.zo -- T
Exhaust Fans
O.K. to Wrap
/ - O2-7
F.A.U.
Framing
/-zQ-eY2,
_
Compressor ,
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-y -
Drywall - Int. Lath
Final
Final P
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
Neater Final
Water Piping//�
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
_
O.K. for Finish Plaster
Sewer Lateral
_ _ _
Pool Cover
Sewer Connection
_ o 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 —
Utillty Notice (Perm) Jl- J
COMMENTS: