0211-113 (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
1/1nt.'r. t..f .a.:.`.i r:�J /S1a:4+.z+':.e", •a'•'.'is,,.,.•+....._..... _
Date y -�" 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).
( ) 1, 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:.
Carrier . ST.A.TC FU14D Policy No. 164002.01
(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 thoseprovisions. TT
1 0 Jr'
.Date: r �r h Applicant �+ ." fi`r,•.. 7 .•^ -
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. lµ`
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. i +,:
1. Each person upon whose behalf this application is made & each person°ate j
whose request and for whose benefit work is performed underor 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. l 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 propertyforinspection purposes.
�r f
,/Signature (Owner/Agent) f; �- ? r= Date
BUILDING PERMIT PERMIT//
iitR
1D`r�l•-1�.�
DATE VALUATION LOT TRACT
JOB SlfE�
ADDRESS q a �. wg d�i a �Z 1 K�.e�e � i
APN 773- 2- 33,
OWNER y
CONTRACTOR / DESIGNER / EN &NEER
,SME1014AWIM04, TKC
s >a c corkpomriollq
77+-5CA C-OMT.1'.fiYr CLUB DRIVEMUM 137
77� 4 S C 01M. TR.Y.(_'L D YiMVR D d ..`. 1 50
PALM DIRMY-T CA 92211
PAI.0 ,13MW CA 92260
`760)772.8224 M0 1Y
USE OF PERMIT
M012 FAN51i.X' 1«iWY.LLDIG
3FI D - 1,07 1, MAN 111, P99f&91'I. DOE?, NOT INCLUDE 8W., CK I'+71y,i LS.
POOL, SPA OR D.FUVEWA 4' APPROACH
f:i7MM CONSTRUCTION 11?3b+®p of
PORC'"ATIO 86.60 Sr
R.,A01FIC'ARPOR.TS '�.Oq SF
3',iA,M CC)lg"1` OF f-IONISIMUi. ON
'1�y, ��{j }n���% qq..1'(�•� �qry'( �'�%�,�;1yL+,gSf`
CONSTRUCTION FEE 101 r01?0,18 X000 $944.00
MECFdvN1C.ALFSK 101.000--421-000 SPLOO
311111VCA r 0.9 -r,0 t20-ci t ,
i'L' PAA:SWO r1% 101-00-419400..0 13'd;, 31t
yT'R.fr3VYQMOTIONMI:-MID 101000443-0003
GRADYWO FUR 101a 000-423.000
' 7DWE1.IDI`ER IMPACT YES
Tt3 i + A:$•Jli PLAN CE E` K ..
$4,523.35
%x,:35 PRE -PAID iTZ3
50100
NOV 2 2 ZM-2 z ; . , S XTE Vidal
$49527.3
(OF LA QUINTA
FINANCE DEPT.
RECEjf?T
DATE � q
BY �F
DATE FIN L -E, `7�
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
/ 2
Ducts
Slab Grade
+ —
Return Air
Steel
/ - Z
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Z —f''3
F.A.U.
Framing
— —
Compressor
Insulation
— / —
Vents
Fireplace P.L.
z
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Top Out
_
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
(' —
Encapsulation
Gas Piping
_
Gas Test
Appliances
Final
COMMENT$'.
Final /r -
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)