0311-069 (RC)LICENSED CONTRACTOR DECLARATION
. H{ 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
N W Professionals Code, and my License is in full force and effect. -
O =) M License # Lic. Class Exp. Date
i
W 6208.9 T3 lu
Z Date ` /*'� Signature of Contractor bf
(DOr;lj I /
J U C:) OWNER -BUILDER DECLARATION
W UJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
( ).-1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co () I am exempt under Section B&P.C. for this reason
U-)
N Date Signature of Owner
O N
rn
U Q 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 Policy No.
(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;provisi s of Section 3700 of the Labor
Code, I shall forthwith comply with4hos provisions'.
/Date: 10 A' Applicant / � -•o' ,v f -
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 3.706
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.
..,'Signature (Owner/Agent) �6�✓``�` r 'f� ^- Date
7,;.t .
r I
y
;. BUILDING PERMIT PERM'��-�
`
DATE ! VALUATION LOT TRACT
11'i,✓ f BJ:Et4C [ � O.C30 PAR. 6 .. 1 liril, 820 0631 1
JOB SITE
APN ,
ADDRESS 47-250 wmarmoToxyr. sum B.643,2W'006
OWNER
CONTRACTOR / DESIGNER / EN (NEER
w4a P ROP i:7ly's
P15 .14MR. C ONSIRU MIN AND REMODEL.
78.1,67.1• WY 111
PALM C %NTY0X 1 R1%JR
LA QtM%TrA. Cr, 92253
P -€1T bl WRINGS CA 92262
(760)275-2891 CBLff
USE OF PERMIT
C(RAW' CTM, REMODEL'
COMMERCIAL - 45V S.F :tRLA.i,' ESTATE OFFICE, INTERIOR TENAt-IT
IN1PROVEM13P4'T. B OCC. TYPEV-Ni VIM COD
CONTRACT AMOU14T I) 5400mo € Z
EE;R ium. -'i (zOST pair conss`TR.1a I`Ao£8'
,: :11-5,0 0,01D
PT RMC1.1 FKF, SUMMARY
CONS T 131.tCTIO14 FEE . .103-000-418-000 S6SQ'.00 . P
P1,AN CHECK FEE 104-000-439-316 $567:41
MECHANICs'aI., H91K. 101--000-d21-000 $48.00
XLECTRICAL FEE 1.01A,00-420-000.
PLUMBING FEE, . 101 *00 0-4119-000 $90,00
S'dRONCI MOTION FRE- COMM 100-000-2.41-000 $24.15
. A •. �' .. - O�TnaCB('TiPT.AI>T13I..iiltil CHEti+J[i
T-1,574.19.
D LY 218 Yn-PAMII�
10,00
NOV 10 2001 ,r 1, P t1WT1111.41 cS EVILTE now '
SUS 14.139
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE i } ',",.} «7
/ / ., l il v %
BY"-
DATE FINALED
/- , Q r
INS CTOR :.
89:
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.
FramingQ
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 Pf fT
Final / Oy
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Outifi ,Q/L!*r/�j'f
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final T
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power % Q S—'
Final a 115
Utility Notice (Perm)
COMMENTS:
��i4ie //i/ ._—>7 /0
OCT-29-03 WED 3:50' PM RIT CO, FIRE P&E INDIO FAX,,YO. 1 760863 7072 P. I
oiler' "
RIVERSIDE UNTY-FIF:F� DEPARTM.�NT
CO
�.c In cooperation with the
uCalifornia Department of Forestry and Fire Proleetton
F _
82-675 Highway 11.1; 2nd FI., Indio, CA 92201 • (760) 863-8888 -Fax (Z60) 863 7072
October 29, 2003
Tom Tisdale
Fire.Chlef City of La Quints
Building Department
Proudly wivutg.thc
unincorporated
areas of Riveimde Re. Fire and Life Safety Clearance
County and Qie 47 25Q Washington: St
Cities of;
Banning
Riverside County fire Department is granting a final fire and life safety clearance for the
group structure located at 47-250 Washington St.
Beaumont
Calsmesa Respectfully,
v ,
Canyon Uke
Coachella FRANK KAWASAKI
.. � .
Chief Fire Department. Planner
Desert Clot springs ^ ��
�• By
Indian weds Terry DeS Cy
�+
Izidio Fire Systems Inspector.
1" Lake Elsinore
v
Le Quints
Moreno Valley
w
Palm Dcselt
Perris
release Iq wpd
Rancho Mirage -
san lacitttn
w
Temecula
Board of Supavisors
Bob Buster,
Disvietl
John Tav4zhone,
Jim Venable.
Visbict 3
Roy Wilson
District 4
'Marian Ashley
Dielrict S
EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE
82-875 Hlohway 111, 2"0 FI., Indio, CA 92201 • (760) 663-8886 • Fax (760) 863.7072