0301-251 (SPIN)BUILDING PERMIT PERMIT#
LICENSED CONTRACTOR DECLARATION
DATE VALUATION LOT TRACT
f / 00 40 2.8603-1
I hereby affirm under penalty of perjury that I arr licensed under provisions of
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Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
76.1'-09(�tD I8
Professionals Code, and my License is in full force and effect.
CONTRACTOR / DESIGNER / EN (NEER
License # Lic. Class Exp. Date
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748004
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DateU: 1.1S1 Signature of Contractor
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OWNER -BUILDER DECLARATION
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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License Law for the following reason:
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( ) 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
$100.00
Code).
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() I am exempt under Section B&P.C. for this reason
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Date Signature" of Owner
Sloe, x)
JAN 2 1 1003
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WORKER'S COMPENSATION DECLARATION,
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I hereby affirm under penalty of perjury one of the following declarations:
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() 1 have and will maintain a certificate of consent to self -insure for workers'
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compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
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( ) I have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
is issued. My insurance
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permit workers' compensation carrier & policy no. are:
Carrier HTATE'f:'OIVII'Y.°?�l£3ATI Policy No. TBI)WC
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(This section need not be completed if the permit valuation is for $100.00 or less).
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() 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
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subject to the workers' compensation provisions of Section 3700 of the Labor
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Code, I shall forthwith comply with those provisions.
Dater!- ? t' «? Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his ;
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
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correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon'
above-mentioned property for inspection purposes.
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Sinnature /Owner/Anentl rj* .. .. Date(31•' j. r';;;1• :'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
f / 00 40 2.8603-1
JOB SITE
APN
ADDRESS SID.. 17'1$ �vrJ"VAGIR
76.1'-09(�tD I8
OWNER
CONTRACTOR / DESIGNER / EN (NEER
9171VEW WAS � F-R.Ht' NTS
Sk°WW WATMUZ 110M
7161 )NDIANA ANT.
7 161 R4:91A:NA ME,
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(.905 ;Y;84-0840 CBIA 535?
USE OF PERMIT
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flWAJ,.1.NS.4?Y+;arx1E: N YOR PF'R.JHT 00H4n (rXPIRZO)
MIMMYD COST OF CONS"MUc.:'Y 1017
primo
P1roRtrRT Flrf 8IM04ARY
VRML INSPECTION 101.000.423-000 UOloo
417
SiJD TOTAL CON47,d.d UWJ..aO Ad`6A.r PI" CMU,
$100.00
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0 1t, I��.at '4IT YZES ID11V NOW
Sloe, x)
JAN 2 1 1003
CITY OF L4 QUINTA
FINANCE DEPT.
RECEIPT
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D T E
BY (
DATE FJJVgC
INSPE OR
n
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final es
BLOCKWALL APPROVALS
D8 $
Fp',
Steel
POOLS - SPAS
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 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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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