0209-095 (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
... X1, � }Y.9C {ata";3la2
Date Signature of Contractor'
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractorls
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 piovided 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:
Carder .�TATE 323D Policy No. V7152
(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,. o the workers' compensation provisions of Section 3700 of the Labor
Code I shalrforthw,ith comply with those provisions.
DE6e: r s.� �—Applicant��
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 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 I
the above-mentioned property for inspection purposes. ,
Signature (Owner/Agent) .r+ r" " "- "' Dated' " +
h
BUILDING PERMIT ,'. PERM T#
DATE ^ VALUATION kSIM9 . LOT ;. 2.0 TRACT 30125`2
0 �•
/- 2l, o ':?--_JOB
SITE
ADDRESS e j -Z I3 A1�' Y4 ` C.�C? l`
APN 773-022-021
OWNER
CONTRACTOR 1N�EER
7+VVpHomy-S,
Ky-S,we
y/EN
//�DESIGNER
gyp
77-564 CO'LiI1Mtt' dLUB DRIVE SI.T.I.M, 1.0
'17-645A COU, N'. T CLUB. DRIVE ALiTM 150
PALM DSEW CA 92214
FAY.MDESIM'k CA 92260
�'dt;41i?b�%?224'I?ik 11'1'
USE OF PERMIT
SNOT..R g.AI MY MR113 NO
S,F0 - t aY 20 FLI#N I R,. l'FAMIT DONS NOT INL:I UDL? BI..00K
W ALIA POOL4 OPA X72 DRIVEWAY APPROACH, 75%2 &DUC.1:i0H TO PLA14
Ciimry 2 &R.. DUB TO MidY3IPLE I,SSOANCE 0? `AY. PL -AN r . EI ;
Ci7WTOINI d`O MTRUCTION 2,236.00 :,'Is'
FORC IPATIO SF
GA.13,A3.Ii,JI,'AXPOI2,! 323A 01F
Effl n" ,x'19 COST OF CON611MIMO--
186,945-20
CONSTRUCTION MIS 1431,00-414.OW $944,00
PLAN 000K FEZ 101-4100-439418 $19123
MECHANICALRE 10.1.000---423,.000 SO1,£t®
XLEC'I'RICA], FIM~° 101 -00"20-000 $122.28
ia4i3R48040 FER 101.000-1,19.1100 siwFa o
STRONi7 MOTION it -E a REBID 101-000-241.000 $IIi.d9
(IRA?PAO PRE '101#04.743.4'2;.•000 MIN
Wil -°MY' L CO IF 2.LiC'il ON—,fit' D PLA -4 C 14-ECX
1 19
O Lr -a r
SEP 2'7 2002
CITY OF LA QUINTA `
FINANCE DE
RECEIPT
DATE By f
DA E FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
— ;2—
Underground Ducts
Forms & Footings
p— — Z
Ducts
Slab Grade
Q —
Return Air
Steel
--,Z
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
Z
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 ELL 3 1
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring2—
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final .� —
Utility Notice (Perm)