0209-092 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of pe�ju`ry 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
5336.701 1 fss's X0 2
D�at'e' fv Signature of Contractor
j 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).
O b am exempt under Section , B&P.C. for this reason
Date , Signature of Owner
d' WORKER'S, COMPENSATION DECLARATION, .
I herr6bfy affirm under penalty of perjury one of the following declarations:
(dA 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 FU14D Policy No. fl7152
(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 shjill fortwith comply with those provisions.
Date: ^ { Applicant
Warning: Fa6lure to secure Work4rsCompensation 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
the above-mentioned property for inspection purposes. "
IMM
109
nature (Owner/Agent) = - - - Date y' 7 �� A-3
C ,� • �..j
BUILDING PERMIT PERMIT#
}r
02W-0502DATE
VALUATION
w.wi LOT 17 TRACT 301ig�
�7_f✓^•
JOB SITE
ADDRESS X290'�k`AIUMICi x f.�+�.��.S�IT
APN 77. —M22-021
OWNER
CONTRACTOR/DESIGNER/EN INEER
i �90.1.UAROMF8,1NC
t�i:�l:Z O l col?"FKfI014
77d50`A +CUUN COX C>:.z.JB WRME MIND 137
77 -(ASA CC1UN1 %T CLUB I)R.V:- �1TSE 150
PALM l:a lrz'U 0."..A 92211
1� l;Ef� M. C CA 9226,
("i x772-6224 M. 1.6 11 7
USE OF PERMIT
STOLE s'�'.A1�t 7LY L l�'L�,.I.7�G
A
STIR - LCAT 17 PLAW 31R, . PERMIT DO i`dOT INC1L.UDE P.L,s7# -K
WALL % P004 ;9PA OR i�1�i� V A.Y APPROACH. 75% RB;t�i;rc'�iION `eco Puoi f
CRECK PRE DUE TO MUI;CIPLE ISSUANCE Off' SAME FLAN TYPE
CUSTOM CO]NOTAUC"TIO4i 44741,00 10
PORCHIPAT1.0 236.00 SF
AGRICARPORT $18.00 SF
XIMMA: ' G0 OJT' LC,lNSIR'IrF�'T'�ON
2.:�1� 9_50
TVR `FEE sum -MAIM
CONS RUCTION FEE 101-t00-418.0010 $4,x,0@
PLAN Cti�f:1,': F 101,-000439^ 113 010:b:3
MXCE0A'i ICAL �'1 E 1011.®0)00-421...000 S10i"
E RICAL,f�EZ 101-.0300.420-0f 0
LeC''1
PLUMBING FES: 1€!1.01 19-0030t
S'TR0140 �.+1C9i('ION FZE - RV.81A 101-000-241.,000 $72.65
G INO FEE 101-000-423-0009.423.101-000-423-000$15.00
DEVELOPER JM PACT P'� E
ART IN P8,7£a1 micis c iS - RFa1i 271-x' 0.445.00 0 166-'8
S11�-:f OYrA3.._ t:'i^I�$1 1 104�'.�m1"3 PLAM C.1:MCK
$4,2,X7.255 '
D
So PST r : UN, NOW
SEP 2 7 2001
CITY OF LA AUINTA
FINANCE DEPT
RECEIPT
DATE ,
BY M ;
DATA FINAS D
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
. MECHANICAL APPROVALS
Set Backs
Q-`7- 0 z
Underground Ducts A.
Forms & Footings
Ducts
Slab Grade
Return Air "
Steel
Combustion Air
Roof Deck
_ –
Exhaust Fans
O.K to Wrap
�– — B
F.A.U.
Framing
_
Compressor
Insulation–
Z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
54,
Drywall - Int. Lath
Final ✓ �j
Final
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 Linesi-�
z
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
AA
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring Z2_ -
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: