0209-090 (SFD)LICENSED CONTRACTOR., DECLARATION,,
I hereby affirm under penalty of perjury that 1.am licensed under provisions of
Chapter 9 (commencing with Section 70b6j`of: Division 3 of the Business end
Professionals Code, and my License is in full•force and effect.
License #: Lic. Class Exp. Date
13 WC
1Date ; _s_� '` "' „Signature of Contrac or �'
^ �.
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 ofrthe property, am exclusively contracting with .licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code):,
O I amexempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
l . 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:.
Cartier STA123, InJHD Policy No. 071$2
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 1 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 fortwith comply with those provisions.
-Pate: -Applica L..�...,—
Warning: Failure to secure Work 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
fora 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 applicator 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.
Si nature (Own er/A ent) Date
-
PERMIT #
BUILDING PERMIT
DATE VALUATION LOT TRACT��'�
JOB SITE
ADDRESS
APN
OWNER
-
CONTRACTOR / DESIGNER / EN (NEER
_ - -
==-fica111TRiy1111M
�9z3�i.�%HOMES, WC
co"ORADair
77 aa6.4 CQT.T1,T R'Y CM DRITWI ME 137
-7 645A, CQUNTAY CLi313:t>R.'t'V F, M.rr, 150
P'A%.m DEM, ZT CA 9221:1
PAW. OBVERT CA, 92260
(760)772'^ST24 QM0 1137
USE OF PERMIT
13TNOLLFA
SIJTJ • LOT 13 KAN 2. P9R341T,DOM'NC➢T INC1,UDE? BT.,P.'kr:.°Y%'IALL.%
P004 SPA 0R ,DKkV"EWA1"APPR,,0ACH. W%13,►?DUCT1O14 TO PIS 049CK
111?E DUE TO M..0Vf1PLE LSSIl'AWC9 OF SAME PLAN TYPE
7
CUSTOM COWSTRUCTIO41 Z400.00 OF
PORC:81.1lLIAXIO 123.00 SF
OATtAOWA.RPOV 6$3.110 OF
E9.MJL .'.rRD C'OSr 0Y CS.3,17WRRUM3 :'3N
2k17.1922.,' 9,
1a Fes° ":9 XWY
CONOTa¢t (MON VX2 101.000-418.001 S1,Q17..q.0
PLAN C1'tLr tai: I'VE 101-000-439-318 007.35
IL ECHANICAU RZ 101.000.421.00 $100 0
ELECTRICAL FEE 101-000-420-000 "01 33.56
P,1,UN13tNO FRE 101.000.419-000 �1a3,d0
STR 140 MOTION PUS a 1''•.£3`31 9 101-000-:W-000 $B4i.7t3
OW00 101 -OW -423-000
Dfs:'VELOPIRP •I.MPACT 1T1r ,rd03. S
.ART 1N PL1I31. C Pi1Ai`.V1,- RESK 270.900-445,000
-TIM3aVM€�'>� 3.10N AND PLA9 C3ZZY,
V.;092.75
MMM PAR -PAM FFM
U,Oq
u 22
D
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e A •p ���y�R�+ ry �.+ �•t7 ;t; ly�y� AP
. - v1 Y'OOdd2RJ Po5w�6`S1Y.SJ:d le� .T.s�.F�i,,T1e L'0b/RLY
SEP 2 2992
a+,e� �y��y� �7
SP`.R{F./.2;7 .
CITY OF LA QUINTA
FINANCE DEPlr
DATE
BY :/ '°' +
DATE FINALED
INSPECT
7�jRECEIPT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
D - 1/ _
Ducts
Slab Grade
Return Air
Steel
p
Combustion Air
Roof Deck
r!- p'
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
/ —Z
Compressor
Insulation
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
3— —
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
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
- CJS
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
_ _
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Gas Test
_
0
Encapsulation
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) ji
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
FuRures
_
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
_
Utility Notice (Perm) 3