0305-060 (PC)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 , y
.111&684 P R,`!'
Dater. !�— Signature of Contractorl�
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).
() 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 �kl�'i�:f= .�jnT,;Q;FNI11" Policy No. 1 X-67101
(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 shoutil'become
subject to the workers' compensation provisions of�1,o.Gtion 3700 4f the labor
Code, I shall forthwith comply witFj`'thosp li os'i r'"� �
Date: t^''c `,d �rfi' Applicant (( �� !
- . r �Ali' V�Ir cs
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 represenl�tives of this City to enter upon
the above-mentioned prope' yff or rlispec,.tien°pu�pos�es.
�/Signature (Owner/Agent) Date �, F ,3
PERMIT #
BUILDING PERMIT
DATE VALUATION vt4s. ii LOT ��� TRACTJOB
SITE
ADDRESS 1/9-772a?��oYl'la.e7dk.,,��4�i.(l.a>,iDC?�T
APN -ii.�C1tv1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
HrJNI.l S Ti 1) Icy
r, 'INC
4000'. FMUZ-Li.-Tslz SSTs B 1
4-00 3. 1TPRRYJ11 DR OlfJ.°I',? P 103
?3�'..,A3 S RJ?dC CA �: : 7
1.��,I: PRITUS �' t, 92'?t a.
USE OF PERMIT
P0RC1-Ul'.A ;r,;, ti'il�
:��".l�r'1,'�;t?"S:' d,��'a�,;:i i'�lr 'i�:C7.+3�Si�JC•"?�%(ff�?
�'.��►7�
T`IAX14 C1i:r-K F&I i 39-3 18 $114.95
C0.' ST.&2UCT1.GA R' tR 1;.11-000-418--000 $23.00
ISTW-14 TMOTIC:N IrZE RXZ'fL'o
[MAY 0 8 2003
CITY OF LA QUINTA
FINANCE DEPT.
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lyza I l�ti:." J.YSStjb � as,
IVYALITRWIC FUS TAIR NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
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
BLOCKWALL AP ROVA
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
r
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:
r
J
Bin #City
of La. Quinta
Building & Safety Division
P.O. Box 1504, 78-495 Calle Tampico
,La Quints, CA 92253 - (760) 777-7012
S Building Permit Application and Tracking Sheet
Permit #��,Ilt-T,-o
S>%r, ��;„ fi#s
Project Address: '7ri -I Z-7
wrier's Name: p/v pGfL(f I" ( IVL
A. P. Number: 6 0 C'( - 386 - 0213
Address: 54- Kir-,
Legal Description: (� 5-p G 2�132�7
Cite. ST. Zip:
f_-�
Contractor: p!0NPS(1,o5A I PNW*- 11 1/VC-
�Krelephone:
WTI Address: T I O W'S- NS GYL
Project Description: M
City. ST. Zip: (,�laSAN N C� a V5-08
M d P -Y /L HOnM LM-OSK, " ",
�4 oF�
_I U p
I �WOOD
'EA
�NrtofS�(3TelePhone•
P 5
State Lic. # : -15-1-524
Cit.• Lic. #: )4 S710
U f y4 - 2-`( wooD G ✓V $ 236
Arch.. Engr.. Designer:.0UI UG( ANG ( i i
�{et QV -W tW`1TUVF, L,,AT P-,
Address: ';jo UNION A-liP IST 17 -VIM -1000
P su M In orL, u se Pmt 2GO3- 3$S
City. ST. Zip: CAMpg C
(` 05AI C- e
ne: �D -O Z3
Construction Type: Occupancy:
:TelePh
Lic. #: ej 2, 7--
Repair a
it DPr
Project i`Pe (circle Nev Add'n Alter
-
0Name of Contact Person: ry . GIW I C4C(1,0
Sq. Ft.:
# Stories:
# Units:
t Telephone # of Contact Person: qZj 51�007'f
C
Estimated Value of
APPLICANT: DO NOT WRITE BELOW THIS LINE
p
Submittal
Req'd
Rec'd
TR.ACKING
PERMIT FEES
Plan Sets
Plan Check submitted
L/
Item
Amount
Structural Calcs.
Reviewed. read• for corrections
Plan Check Deposit
Truss Cales.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2"" Review. ready for corrections/issue
Electrical
Subcontaetor List
'Called Contact Person
Plumbing
Grant Deed
Plans picked up
SALL
H.O.A. Approval
Plans resubmitted
Grading
11 HOUSE:-
Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact, Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
T/(s 3A/CIF To 040"- 6✓t iIZ3103
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64
M
YOUNG LNGINE-J�RINGSERVICES .
Engineering Architecture -Surveying - Building & Safety Services
Letter of Transmittal
To: cw�
Date: I z , 103
Project: ��.
Attn: W.O.:
Tel No.: Tract No.:
We are forwarding:
No. of -Copies
I.
Comments:
This Material Sent for:
Other.
By:
Phone #
By Messenger By Mail Your Pickup
Description;
IC
al��
Your Files Per Your Request
Your Review Approval
Checking At the request of:
77-804 Wildcat Drive, Palm Desert, CA 92211 (760) 360-5770
Bronz Young