0204-217 (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 11137 £ /e ;. y�� 5,x:41/03
Date, ��/r, � - 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.
V) 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 ZENITH INS. Co. Policy No. ZM23945D6
(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 ortl7,with comply with those provisions.
Date: `f.` n� Applicant_
'
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 representatives of this City to enter upon
the above-mentioned property for inspection p,urposes.
Signature Owner/A ent
3 a
BUILDING PERMIT PERMIT#
DATE VALUATION LOT y317t TRACT
JOB SITE.•
ADDRESS ..,'1*•9Eifi irMgK0'PF
APN
'102-170-013
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
C:A.'1 19TOMRS GOUT WVST, LLC
D11 -T01 X11VF, Nx'507 'f COid�Mi:fNMIES, INC.
200 X IRAM O'i'QX AVE.
2n01w. VW:11TNgr,)N /' rx f41®0
ESC"OA►TDIDO C.Vk 92025
ESCONDIDO CA. 92025
'
(760)839.8238 CH14f 5413
USE OF PERMIT
Sh1CoIZIY'A1u I;lfD11TT,LIN $
S11). LOT :49, PI.A2.1 2.2A. PERMIT DOES NOT [MCLUOE BIA)Cl£,
WAi,I.,"i, P004 SPA. 47RDRIVEWAY APTIRO.ACH, 75% R1?,Cs1Tr; T1014 TO
P4A11 >1FIFCK FEE t'OR MULNIP1,F, ISSUA14CE Ot SAMIT P!.,eiN TYPE,
CU54TOM C014STRI.00TION ;V A4100 'IF
PORCH/PATIO 798.00 SF
aAr%,ACWC'wAR1'0RT 761q.00 sfr
V.I;JrWA!IXD COST OF CONSIR'liSLMON 320*786115A)
11INTMIX fa' 'L SUNIA+F�I�.i:2.'�
CONSTRUCT1014 KE 101.000.418.000 $1,03,00
Pl-.A,N CH CK.' it'E.ir. 1.01-rOW-439.318 $296.11
11 RO tAiHC°.ALT+RE 10av000.4111.1-000 $11100
1:1XCTIZJCAI..VER 101 -MI -474)-000 W4.12
'PLUMB NO FEE 101-000-41,9-000 $205.15
STS:C}NO It O11CQN IqK - F&S11) 101 AW -24 4 -000 $31019
ORADING PEI 101-000-423-000 t2trtA
2MPRAS;Rf. CTUR FLS 21,25-000-443-342. $1,9ract0
ART IN PUBLIC PLACES - I3.lJ,�IL 270 -000 -445 -WO t34IL07
f4J.8"]{.JrAt. vowirkll=OW d'Yirod..`,FS..[rTitV ti...i•eE�i.riit.. $4q501.30
1YZS FRE4VAID F90 $0.00
., -TUEAL P.kiMf FEES IRTE If OW
i'
CITY GIF LLA QUINITA
rr
'RECEIPT--- �`_ °V�^�`
DAJ) 7
BY jj
JN L INSPECTOR
A
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_
—WFireplace
Vents
P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
_
Final
Final �_ _ _
iE:A
—1
POOL.
g PAS
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(,JboZ_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral A
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test 7�/b
Appliances
Final
COMMENTS:
Final
�1 /
Utility Notice (Gas)
ELECTRICAL APPROVA^
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
_
Temp. Use of Power
Final
Utility Notice (Perm) , , I
May 21 03 01:04p EAGLE BEND
(7601 771 3902 p.1
MAY -21-2003 WED 11 18 AM IMPERIA ERVICE FAX N0. 9096823406 P. 01
T RUS EL.r INCA YFL.: (909) 920-4Q:i� I F� (909) 920 54x0
14 JO E ' Arrow Hwy. Upland. CA v 1 186
L : SLP M it� CI F t4�, SCA E� t LJ rl
I I( I -tot? groU e ri Pc L. Im I-1 Irl 5
�O : q'
6k . too -'►�1
0�2
F46;�. 6.30-03
No. 0053621
IV