0108-284 (SFD)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
��--�'�••_-�f/
Date' ` Signature of Contractor'
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.
(Q,„!.,Jhave and will maintain workers' compensation insurance, as required by
Sectio"n 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 Policy No.
i�+ii` H D121 Co. 2AW2.1194506
(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., shall,orthwith comply with those prov'i'sions: f
5:.w,.1`17
Date: 9 — --,f ` Applicant,,-_ -, t =
Warning: Failure to secure Workers' Com4e/2sation 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.
pplication.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 pu1rposes.
Signature (Owner/Agent)'—f —k , ^ Date'''d ~
BUILDING PERMIT PERMIT#
DATE VALUATION _ LOT hf
r
TRACT
L '54
28444
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN INEER
CAP-°A.`%'lmn GC?ue W:i r, Lit-,
INNOVATIVE. RESORT COMMUMUES. WC,
200 n, VI'MIMPM AVE. ii S 100'
200 R ``Alba AN "r: ON AVR '0100
3�;Cj4�1 C r',A 92021
ESC''-`^.,NDIDO
CA 92025
Q60)$39.821.8
CRU 5413
USE OF PERMIT
ONC$7..'R FAMM'S(`'(7W(.l.. NO
SPU . 2a2,AN k.1A, LOT 54, lrsPMNOT DOES 1tif0T ,@I•,=AJbP, POdZ.LISILA
BLOCK WAJJA OR ORITWIMAY APPROACH
0
tALI2 9 2001
CUOTO CONSTRU�� ON : mxo OFG
POR.t;1i PAsTIO 694,60 t7 C17Y OF LA QUINTA
01 AGEMARPORT 689:00 SF
Y.
FINANCE DEPT.
, 'JJIY�i .7..R1 FA Myr OF C014'�r'�`RUr_11110- `T
h,�L�7/yf. 8,7
�" 1�l�ti'RZxCTlc�1�i �}° ICfi�C�fli3�llt3�q(! 51,30,00
PLAN CilECK, Mr, $1.090.26
MXCHANICAL F91. 101-W0,421.000 %U8.00
101 -000 -420 -WO $151.85
Pd,>UMMO MR 101.000.4194t} l $210.50
1"ROW MOTION "M o PY_g1011-0I£-241-000 $30,02
\C'M04-1 gqff,' 141 -000.423 -OW
_73;YMDPY.11,IW-PACT �{s_t1!
ART IN FAIR ,I'C;; KAMS - RESIE 270 -000 -445 -MV 16i1'4t.3
NL17?i_ TCY:t;bl.L t:tiwmltuC"1foAa AND PLJW CHTICK
$5,160.83
JAMSS .PRR-}''A11*%FM $50100
RECEIPT ..ti•.
DATE, /
BY
FI L
I PECT
t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & FootingsDucts
Slab Grade
/� / ��
/
Return Air
Steel_
Combustion Air /
Roof Deck
�/3/(,�%
Exhaust Fans
O.K. to Wrap
1
F.A.U.
Framing
Insulation
/001
��Z V-0
Compressor -
Vents i
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final—f�-
- - /— -
- - -
POOLS - SPAS
BLOCKWAL
IdL ePROVALz
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines9��G/�
_
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection/c{�
_
y �yS/
Pool Cover
Encapsulation
Gas Piping
Gas Testd
Appliances
Final
COMMENTS:
Finalpl�j-
Utility Notice (Gas),.3
ELECTRICA
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
--A- -7
—Final
Final
Utility Notice (Perm)
TVIA W