0010-048 (RPL).G
LICENSED CONTRACTOR DECLARATION
I If reby#Irm under penalty of perjury that I am licensed under provisions of
Chapter A -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
574127 A '
• Date 1 ,- ignature of ContractonG�
• �.
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.
have and will maintain workers' compensation insurapce, 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 Policy No:
T.A IIE FUND
(This section need not be completed R 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 t�ho� 'I Isio "
%_/date. E&i � Applicant -
Warning: Failure to secure Workers' Compensation coverage.ls unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. >
1. Each person upon whose behalf this application Is made & each person at
whose request and for whose benefit work Is performed under or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, Indemnify
& hold harmless the City of La Quinta, Its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void If
work Is not commenced within 180 days from date of Issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this. City to enter upon
the above-mentioned property for inspection purposes.
'i� ...,
Signature (Owner/Agent) ��'��• ' ,�+rt`""ry Date ,�`�
BUILDING PERMIT PERMIT #
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
45-435 1�1�:F:,R13F?.001K M.4 LIK
-
OWNER
CONTRACTOR / DESIGNER / ENCIINEER
MW BMW
�i.�,VE M)7 SON (1:014"TrRUC, ITON 1N C.
45.43115 1)l31i1 AOCIIX ORO r?
-13017 f'�c��ixt �°IZY�Z,Y3l� i?1�.M3Ta: k4
LX QUINT°A C;A. 92253
PALM T)F,,;'fkt1 'CA 92,260
(766)346-4032. oDvt 1041
USE OF PERMIT
:1'OCiLAND/0R. 8PA
P001. &SPJA ONLY-ALARM.1t3aA121 IMS SHAl,d.• Be IN PLACE AT PRE
PLASTER INflF'tiS1. TI(. W.P00b K)UIPWiENT F44t".Lt'1WRE 1S NOT 1NCLUC►t D
1N THIS P.V'RM1T
POOL ANDiOR SPA 1#130D.00 1.Z
J961.'3MA'lIM l:09C 01W Cf?1!ra'1','�'�UCrTION
:kNUX)
,*Y0.YRWr Fm 9I:1i1IIMtARY
PLAN CHMIK E 1014100.4.39.31$ V11-7.0
CONSTRUCTION 1r'>FF 1101-(T( _418-000 $190.08
149C.tiANICM,".E--POOL 101•'000.47,1.000 $214.00
T.P.L=3`RICAL FEE -= POOL 104-000-420-t`.00 $45,00
t'L,Uk4f1�i?dc1 T+'1?P, . r00L. 101.000-419.000 $27.00
1
9MI-111(yrAll CHT1-Pq(!f10 MD PI" 017Ii K
$393.00
PAID' 1103 FR.'-PALS)1r3%.F O
$0.00
OCT 10 ZWU '� rAl' 1"`KRN"1.1PX'1-4 1)T1F- -o w
gm>tiwu
Ut-)LQ(,
RECEIPT
DATE ,:
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
SULD6NG APPROVALS
'Set Backs
MECHANICALL. APPROVALS
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Alr
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
Finial
POOLS - SPAS
z�,PPROVALS
Set Backs
Steel
Electric Bond
Footings
Main Drain_
Bond Beam
_
Approval to Cover
_
Equipment Location
Underground Electric lq 3p
-Final
Underground Plbg, Test A 5_ � y
Gas Piping La(.
PLU+9I M l'G APP',ROVALS
Gas Test r!�3� Cd.0—c"
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation o�
Gas Pipings
p3.O
Gas Test
Appliances
Final _ 40
coa m-E '
I �j
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
Fina(
Utility Notice (Perm)
a�
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FORT CONSTRUCTION
Aldi 1 A t` !R R!E _ ()A, 0A
tsl-r'
LITE
�oo
m RESIDENCE
P'
F A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND 10B CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
NO Ei(OEPTIONS!
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PALM DESERT TEMECULA
73-017 COUNTRY 29910 RANOID
CLIIs M STE F-4 CALEOR16A, RD.
]W=I' SCALEPAIN DESERT CA STE 203
MOM LANDSCAPE AND FURNITURE 92260 92TEN5ECULA CA. m
ARE SHOWN FOR ILLUS'T'RATION (7601 2464012 (9�SZfrS1 N
ONLY AND ARE WM INCLUDEID
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