0210-207 (SFD)BUILDING PERMIT PERMIT#
LICENSED CONTRACTOR DECLARATION
DATE r! VALUATION LOT TRACT
r 169- 50357
I hereby affirm under penalty of perjury that I am licensed under provisions of
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Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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Professionals Code, and my License is in full force and effect.
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License # Lic. Class Exp. Date
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I iS99 B 04-1dP2C
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Date <'_ Signature of Contractor
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OWNER -BUILDER DECLARATION
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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License Law for the following reason:
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( ) 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
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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
CONSTRUCTION FU k 01.000-41 8-000 $I,4$.0.00
Code).
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() I am exempt under Section , B&P.C. for this reason
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Date Signature of Owner
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
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() 1 have and will maintain a certificate of consent to self -insure for workers'
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compensation, as provided for by Section 3700 of the Labor Code, for the
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of the work for which this permit is issued.
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( ) 1 have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
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permit is issued. My workers' compensation insurance carrier & policy no. are: `
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Carrier LIBERTY MUTUAL K Policy No. WA262DOW-123DI2T '
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(This section need not be completed if the permit valuation is for $100.00 or less).
RECEIPT
() I certify that in the performance of the work for which this permit is issued,
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I shall not employ any person in any manner so as to become subject to the
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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 shell fo hwith comply with those v Sio s1,
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Date: Applicant ;4l �i` / �a�'u^"-^~
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. i
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
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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.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
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DATE r! VALUATION LOT TRACT
r 169- 50357
JOB SITE f
ADDRESSw - iW.5 -C. Vl"�xR..�lDi i ��l�
APN
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OWNER
CONTRACTOR / DESIGNER / EN INEER
TOM BRC?'.Cf��i1M WC
1101111 BPI0TBIM,1'C
74.923 ..1-IOVMYL,AKEr"7fNU ':i 12-220
4-923140V LY 11 MEMOP 11;l)MR2_220
PALM D 1.4;`Mx a.IA 92,;60
W"'i 1MERI; CA 92260
Q60)674»909 CTU 383'11.
USE OF PERMIT
GIE VAgFiF.it., fr':���UNG
wIrFJ LOTI64, >fii Ait.e tArA.. I>AI�'MIT 110ES'NOT iiaCL,unw bL• xx
YALIAPOt)I, OPA OR WgB'VEWAY APPROACH. 1% P03fC:t>2"rI N TO P1.46.N
CHECK ME, DUX TO, Ilr131t TIPL E Ia:;L1t'NCE OF SAM IlVita TY11Z
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CONSTRUCTION FU k 01.000-41 8-000 $I,4$.0.00
PLAW CHECK I rg 101-M-439-318 t2,Rtb.76 .
MECHANICAL ANIC.AL 17EE 101 -ON -421-000 $143.50
EL.RCTR: M,1q* 101.-000-42t-000 PIZ1a
PI.f3IwiBIM F1:.,E 101 -WO -419-011V $111.?.$
STRONO MOMN YEE , W. 411 101-000-24 1-GLO $33.611
GRADR40 "F. 101.000- -000-423400 $IS106
IJZbY:WM IMPACT FEE v,.40.1.00
ART IN PUBIX PLALM - R -9,,11K 270-000.445.000 $2,41, 779
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FOCT 31 2002 J
CITY OF LA QUINTA
FINANCE DEPT. ,
RECEIPT
DATE
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FIN D
I PECTO.
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OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
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Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
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F.A.U.
Framing
Compressor
Insulation
,p 3
Vents f
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
1
Final
Final
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POOCPPAS
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
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1717—Y- 02 t1.L(�gQ,�D
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
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Pool Cover
Encapsulation
Gas Piping
Gas Test
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Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
50-2
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ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
_
Exterior Receptacles
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G.F.I. /
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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