0211-114 (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 # ei� re Licc. bass Exp. Dates �y ��y�
5.33V70 � l�i�� "': ' Qr':76Y04
de
...-Date �f/'' Signature of C tracto _T
OWNER -BUILDER DECLARATION r
I hereby affirm under penalty of perjury that l 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
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 :aTAT,1s TrotD Policy No. J640462-01
(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 those provisions. �;
Date: / ` , ,i " , ^";Applicar1. - d•�a. �� �.t . ? -a .-: f••
.� a .
Warning: Failure to secure Workers'r`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 pursuantito--
any permit issued as a result of this applicaton agrees to, & shall, indemn, 1
& hold harmless the City of La Quinta, its officers, agents and employe yt�+tJ,
2. Any permit issued as a result of this application becomes null and voic if
work is not commenced within 180 days from date of issuance of suit
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 buildirjg
construction, and hereby authorize representatives of this City to enter upon'-'"'
the above -mentioned -property, for inspection purposes. ,
ir�.,s 3�-� ti�.--
Signature (Owner/Agent ).---• '� Date
�BUILDING PERMIT • PERMIT #
tbif-�A
DATE VALUATION LOT TRACT
Ir21
JOB SITEAPN
ADDRESS SOL.15,5 VAIXKCIA COr= i P -Yl r SIS.'b
OWNER
�y�i�y 9 HOW-
_ry��•., et � � 1•r a
6J8:.iii014A HOW- �, J T7 b.
77.564 CIDIAMIRY CLUB IM"Si�,'#"3Z 1.37
%BALM 1 ESM CA. 92211
USE OF PERMIT
81k7GLE FAIt%.Y i7WEIDIG
VOOWWA. OP. DRIVEWAY A.PPRIOACH
CONTRACTOR/DESIGNER/
Si3fi%i40SE C:ORPORAIION
P-ALbi DR M,*f CA 92260
(760Y?72-8224 CS'11.7
CUSTOM CONS-k`RUCT1019 M90.0 3,F
poxciii/kvo I23.06 SF
0ARFtC)F,3CA1:Y't 11t 663.00 SP
;C:xrAWA.M C091'01V £"ORMUC'A O
x': 'AW' BTE 'hTbVJ A'
CONSTRUCTION FRE 101.000418-000 'S.401�;�
PLA14 CHECK fup, 301-000-439-318 $919.40
MECHANICAL FF19 101--000-421-000. R49145
Eb..3rECT.IUC.AL FXF, 101-000-42Q-OOO
PLIlA S11�iO r 101.000.4194Q00 9165,00
5Tk2f,FNO NOTION FFM *�. SID 101-000-241-060 $Z.
®.?r8
OR DTHO NEE 101-000-423-000 815.00
DEVELOPP;R PUPACT "PF $A405.00
ART IN P1U8LIC PLACES - Rt'981E riC-000.443.000 120,00
s ;
"3I.a��...-1 L COARD PT A1S 'i X
LESS M, :PALO FRES
TOTAL PYANUT MS DUE NOW
,OV 2 2 I1 a� J�
I
OF LA QUINTA
Al' CE DEPT.
t
$4,115. ?A
XOD
$4,71115.24
RECEIPT DATE D tNALE INSPEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Z-
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
— —
F.A.U.
Framing
—
Compressor
Insulation
_ 3
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
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
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
_
0. K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
—
Encapsulation
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
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
G - lG -s