0204-071 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H 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.
:5 M License # Lic. Class Exp. Date
r* LU r• 533670 Bh1c; �� 613l2ftJ2
cZ r-_ Date Signature of ContractorCD
O Ir
UOWNER-BUILDER DECLARATION
HLu r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
( ) I, as owner of the pioperty, am exclusively contracting with licensed
1 contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C0 () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
O rn
d Q WORKER'S COMPENSATION DECLARATION
p 2 1 hereby affirm under penalty of perjury one of the following declarations:
U-) oc
0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X WILL compensation, as provided for by Section 3700 of the Labor Code, for the
>.;•:O J Q performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
LO Q Section 3700 of. the Labor Code, for the performance of the work for which this
<.,� LO Z permit is issued. My workers' compensation insurance carrier & policy no. are:.
CarrierPolicy No.
ob'f.3`11,.i�tJ2�8T3 fIrY12
r-0
J(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
3 Code, I shall forthwith comply with thosa'provisions.
Date: , r , Applicant—
Warning:
pplicant _
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 " r
& 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 t
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. `
J
Signature (Owner/Agent) '' - _ _ Dater . :� ..•.
BUILDING PERMIT PERMIT#
DATE VALUATION LOT {� 021'04-071 TRACT r�
ADDRESS 511 I X,,_, opAIVATl12 ® '11�
APN 77."'2-2_021
OWNER
CONTRACTOR / DESIGNER / EN INEER
W1111014A, HOMES
6014RUn CU1~C:F'OR 11014
77.564 C01.11afi.481' C.LMEA DQE, 0137
77.645A CO 'MBB t'i.,UB 1AM : TrE 15C
,PALM DnER,E CA 92211
l?XM tJ wWr CA 92260
",160)772N8224 t.', IA4 1137
USE OF PERMIT
SFO . LOT 70 PLAN 3R_ PERI IT Y7OP NOT INC:LUf30: BLOCK
WAJ. L% T0014 SpA d11.DRNAWAY At'PROACM, i1�96 �I��1� �:11Ec'1i I+17;
,UMUCT1014 PL91`'!,MULTIPLE, .ISSUANCE 017 SAMZ PLA14 TYPE
C.i3.;J'%'c.' M CONSTRUCTION 21620.11-M FIT
r��a1�.G1ti��+'rlc� 216:Ott sk
�:
1�y� '.P1.b�fi�TKD G'os' QF �„'4��3`n`"v'1TRU(:;� XON
•j�
220,019 �:0
7TN yf���y�yy 7�. spy p��
d-,i1.RD1 T FIM L%V�3
COi1'01"RUCTzCtA FRE 101.000-418.000 $1406100
PLAN Ck1T.,C1:: FEF 101 -OOP -439419 $215,82
MEC1iAH1CAt FEE 101.000421.000 S102.56
ELHICTWCF►L YEE, 101-0t?O.420-000 $138.12
PLUMBING MR, 101-000-419.000 M 3u','e'3
PRE �.: PESID 101 -x/300 -24.y 1-(('k?(0 112.�00
.�r($1loggrjt1c p��t�'}c'�')`�ION
GJ3�M.&. INTO/ I'F-11'r F V' 1 R'4I00,4 5. -000 S20.1110
1011400,423 -000
114PAC7 & �1,907,0i9
AV 114 PUBLIC PLACES RES11 .270-000- 445.060 $30.05
t � 4
w11J1 -WA£CO1�3"(�t�7C'1:110M AND :C)LA).+T CW&CKC
$?,,5 '1?: 4
'i lrw 15 ZOu% i ! °.oaf,";I'.S'PM1;4:' TS ME ROW
$3,690,74
RECEIPT
DATE
BY (,
DATE FF ED
INSPEC R
�
L/ i r
/
-�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-
Underground Ducts
Forms & Footings
Ducts
77
Slab Grade
tl I
Return Air
Steel
Combustion Air
Roof Deck
_
.i (j
Exhaust Fans
O.K. to Wrap
—0
F.A.U.
Framing
- G �_
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
i /
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final "/ —
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
Sewer Connection
_
_ t� G f�
Pod Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final Z
Utility Notice (Gas) c,
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)
COMMENTS:
,