0204-063 (CRES)d4 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 3'6f the Business and
Professionals Code, and my License is in full force and effect..
License # Lic. Class Exp. Date
rr t�b�
7 7 r' i nature of Contractor ' x �' J[r1�Y'^_ !� .�
Vate �$ 9 __. �. `-- ...
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am explml pt 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.
( I have. and will maintain workers' compensation insurance, as required by
Sebtion 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 � ATR FUND Policy No. 154, Y-0.1
(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 no't employ any person in any manner so as to become subject to the
workers' compensation laws of"California, and agree that if ,la•should become
suglect to the workers' compensation provisions ,of,Sectionk3700 of the Labor'':,
C6de, I s alLforthwith_comply with "those provi ions. J
vDate:0 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 fortli";;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 ebove-mentioned property for.inspection purposes.
Signature (Owner/Agent) f'""---"`� ' �+ DateTp
PERMIT"
BUILDING PERMIT
DATE,, tVALUATION LOT TRACT
JOB SITE
'ADDRESS "i #Ik Vlg l,.A
APN
'OWNER
CONTRACTOR/DESIGNER/EN (NEER
WROF�'tF..�i,. 5,NMR-19 . S
'3 E£3 iTa, . CONSTRUM. 014
YO 13OX1;510
7%-151) CALLE %AMPICO SUn' fW9
LA Q:L) A CA 971,53
T:tiA Q13'sNTA CA 02253
CUL0 2261
USE OF PERMIT
0AltAO.. OR. d:.`tA3ePORT
Y CRICE .PAT(0 di' W?
OF COARRUCITION
PFRUIT'1•.C. SUMMARY
'MAN C'.Mr'4;XVirg 1C1"Qlti���� d18 $yi3 Wit!
009SIMUCUION PRE 1.011-0,M413-00 SIM -00
3umNamio7sl%?nmm - comm Y,Mf)W-243:•W1
`b
tl
® %Jw L C<ONRYRUC1ION AND13 LAN CIM,C K
N` d n, S PRE -PAID FERS
.f3s
0
ECEIPT
bAfE „
BY /
DATE FINALED
INSPECTOR
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
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
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)
COMMENTS:
Bin #
City of La`'C uinta
Building &r Safety Division
Boz 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #P.O.
0 3
nZ��.
Project Address:
� ` �
Owner's Name:
A. P. Number:
Address:
" a _ilb 7
Legal Description:
Contractor: -7
LJ. Vv
City. ST, Zip:
Telephone:
Address:
Project Description:
City. ST. Zip:
Telephone:
State Lic. # : % C
Citi• Lic. #:<7 Z 7 I
Arch.. Engr., Designer:
Address:
City, ST. Zip:
Telephone:
State Lic. #:
Name of Contact Person:
l
42 ,�i�j.t (
Construction Tvpe: Occupancy
Project n pe (circle ane): New Add'n Alter Repair Demo
Sq. Ft.:. # Stories: #Units:
Telephone # of Contact Person: -7k_6_;;2/�
G�rj�J.�
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW.THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Z
Plan Sets
Plan Check submitted '
y J
Ua
Item
Amount
ZStructural
Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs..
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-.
''' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
OF ° ME'M0RA,NDUM''
To: Greg Butler, Building & Safety Manager To PWD.`f .
From: Steven D Speer, Senior Engineer.
r i Building Permit Release
y (this is an approval to issue a Building Permit)
The Public Works Department has reviewed the following project: y
Description:�/iZICI� G� l2 EGG is
Address or general location: 03 PyEN rJ,0A
APN and/or legal description: 7%3 075- Olp
The .Public Works Department finds that:
r: `issuance of this Building'Permit does not require Public Works
Department approval.
❑ ... issuance of this Building -Permit is approved by the Public Works
Department. '
Steven D.- Speer, Senior Engineer . Date
1