0010-087 (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
19
VDA— 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
, a ...:.
I hereby aff.irm±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. -
( Vl have and will maintain workers' compensation insurance, as''required by
Seon 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.'
$T.A%T9 i°Mp.Ma ly I5424. 00
(This section need not be completed, if .the'permit valuation is for $1'00.00 or less).
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' compensatlo prove�,s�ons of Section 3.700 of the Labor
Code,, l shale fo with comply with tVi a pl'ovisions. `
Date. � ,.t ',� '"" APplicant��,g _-.•`"3� :�'.: t � '
ff €,t'. j f '
tsPWarning:'Failure to secure Workers' ComPensation Coverage is unlawful and
Shall subject an employer to criminal`penalties and civil fines up to $100,000; in
addition to the cost of compensation; damages -as provided for in Section 3706
of the Labor Code, interest and attorney's fees:
IMPORTANT. Application is he made to the Director of Building and Safety
for a permit subject to. the'- conditions and restrictions set forth on.. his
application. ;
1. Each person,upon whose behalf this application is made & each, person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall; indemnify''
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null.and void if
work is not commenced within 180.days from date of.; issuance of such
permit, or cessation of work for 180 days will subject 'permit to cancellation. .
I certify that I have read this application and state that the above information is
correct. I agree to;.comply with all City, and State laws relating to the building "
construction, and hereby authorize representatives of this City to enter' upon
the above -,mentioned property or inspection purposes.' J.
�¢t
ignature (Owner/Agent) k' �- f Date
w
BUILDING PERMIT PERM T#
DATE } VALUATION LOT TRACT
169 26152
JOB SITE
APN
ADDRESS
4? -IW WA ORMTO
OWNER
CONTRACTOR/DESIGNER/EN (NEER
D.17FL41? "I
T i�iC? "ktl�, `�«fit I 1361 �' L"►�iT7 t7 � 'y�17i
77 Wyy56 �.�c�'UMMY t IfDR
'LUB 7'95&4 A COUNTRY LU TS W?.
s�A
A3{�.�a.+L'N'11?,I*.a"r R"r CA 92211
PALM f.' :CIA 98211
9 9th$ -3495 CB10 6133
USE OF PERMIT
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TRACT C010TRITTION OF
PORM.rPATIO .' / 4&00 P
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1.26y21WOO
`10H .M. 101 -000418-000 x'1~4=a,t3U
PIKS' CHIECK 109;9 '101-000-439-316
A?'n,.Y e',UCAL172:ta. $11&42
PL.•AjM140 E 101.000.4,19-000 $160175
mS7l a mG?'i'lolq If' • 1�: w� 101-o o w. -000 S IlkO
101-.000-423.000 520.00
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AF
rRECE*I.PT
DATE f
!� t"<
DATE FINALED
INSPECTOR
"
aJ*.•�! f�,
INSPECTION RECORD
C OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
J / c� ? -
i- � -
Underground Ducts
.
Forms & Footings
/ (mo
Ducts
Slab Grade
Return Air
Steel
Roof Deck
_�
Combustion Air
Exhaust Fans
OX to Wrap
��-� �'
F.A.U.
Framing
Compressor
Insulation rZ 22.3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
LY•
Final
POOLS SPAS
-
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
Waste Lines
71-76—W AM
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
�/ �w✓�
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
Final
Utility Notice (Perm)
-
C
- -w ' Feiro, Engineering, Inc. k�
Civil Engineering- Land Surveying
{' P. O. Box 12980
• Palm Desert, Ca. 92255
(760) 346-8015 k yI
FAX (760) 346-2548
,z Oct. 18, 2000
City of La Quinta
' r 78-495 Calle Tampico - ;
La Quinta, Ca. 92253,,
ATTN: Building Er Safety:: .
RE Lot 169
Tr. 26152 ,
APN:643-160=043
This letter will serve to state that we have field checked the pad
elevation for the above project and found them to be as follows:
High:', ;. Low: � � .Plan:
Pad = 61.5 61.4 w 61.4
- • Sincerely,
4
FESS/0k _ .
D. mes D. Feiro,
°rM Vice President
Noi C-24176
RCE 24176 .
CIV L
. , F OF CA ,