0212-153 (CP)I
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
"'bate !,' '� Signature of Con` tractors
OWNER -BUILDER DECL/ARATION'
I hereby affirm under penalty of perjury that -I am1exempt from the Contractor's
License Law for the following reason:•___, I. >
( ) 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).
O 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
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 ICLrIVii''2 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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to'criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives -of this City to enter upon
1;,
the above-mentioned property'for*inspecliefi purposes._..,
Signature (Owner/Agent) _,'"'�'Date
BUILDING PERMIT PERMIT#
• 0?12-I.S3 �
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 1-;:11%r 3'
APN Y
OWNER
CONTRACTOR / DESIGNER /EN1NEER
51LYJ1- YlAliR HOMM
J?AN0143P0,0AND 71>15ti
1119 )IND'fNAPE
77-70CT??MUxE1,11M—P B
R -TV IDE CA 92515aa
LAUM gEAIMCA 92,2 1 1
USE OF PERMIT
Mf8C1IT-12 A N'. L. Ca't ,8
-A
�uF�£a9��3'+9%t�6'Tda.L'TO 1'tJl�.itAl9' {� Od(►�f�t:i8 Ri?i�B,:L�C'Tt't�it� C1i.K7+ii#� iii
COitIIAc"TOK AND TO cOMPLE ► r? CONSTRAJCTIOu raf..rta TO MIRED
PERMIT
P001, ANDA',1% SRA u.
FM RIMMily
PLAN'HECK f'liIL, 101.000.439-318
FM 101-000-418-000
-418-000
MECI'I.ANICAL REF -= POOL 101-000-171-000 924.0
RIaC,TRZId:.F LTrL�'$`;. - POOL 10e -000-420a000 $45,00
PI,UNtt 1xlO PU -: Pool., 101-0004-1 9-000 SPA
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US,)1a&1AM ICES
1yy4L P,,M.ThX_S.1KIE NOW
JAN 15 2003
RECEIP
CITYFrEAA
� QUINTA,
ATE D
INS
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NC.E DEPT. 2
e
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
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel —
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric �341
—
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric Final
Waste Lines
Heater Final
Water Pipiag
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
/k A
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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CITY OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS f } It�.r-r�t 6� "' PERMIT NUN1SM 0WNER ST6ry6eau k%l9 ���.r✓'7'Z8UILDER_��r¢.:aot•� OUtrs
This tot shay be paatad on the lob with the @tllkillag Insoac*11 Card atoll times In a coonseoe oula Wim. Only persons appearing on thio list or thair employees are authorized to work
on this job. Any changes to this 1111-1 must be approved by the Building Division prior to commencement of work, fa' wil! re It to a age of work and/or the voidance
ef. buildina oannit. For each aovficable trade. all information requested below roust be oompleted by avoNcariL '0A File° is not an acce table reseense_
Trade r Ctassiff"dw
MUM
oarapeny Name
Stats Conaeetor's Ucende
Classification. Umnse Number
Wit. A. B. C$1 laxiinx)
Eta. Date
Isxixslssl
WWWS Emysibn
Carriar Name
(e.g. State Fvadt, calcomp)
Insurance
PaRry Number
IFernm Varies)
tap. Date
IulWasl
city Badness Lieara,
Uaerne Number Ev. Data
puss) luixahal
FAxslawoRtt 10 -121
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11.30.03
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10-2-146
FRAMING (C-6)
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SFfi£T PETAL IC43)
R.GOAING IC -16)
OLAZIN4 (C•171
1 ULATION IC -'l)
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8EWAGE WP. (C-42)
PAINTING CC-=
CERAWC TLE W-641
CAeCNETS IC -10
FENCING 16.13)
u11MARNG IC•271
POOLtGb91
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SUPPLEMENTAL F
SUBJECT
ADDRESS
REMARKS:
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DEH•SAN•118 (Rev 8/02) 1 , — Distribution: WHITE—Office; CANARY—Owner; PINK—Office
r
Bin #
City of La Quinta
Building 8t Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address:` j�� ����Ir ��j
tt•ner's Name: t+jg a / 7-7—
TA.
A.P. Number: //�?�� �j 6O j r
Address: %� — %QCT lyi-l�L />IN�T� L
Legal Description:
Coi
Cita. ST. Zip: _f JlZa/ /
Address: 77 %00 �a AIW •
Project Description: f Oct tr
Cita. ST. Zip: i -. 90
Telephone: z%— ..529 00,4-'-2c_v�j��
.
State Lic. # -.90 Cin• Lic #: 3%.s�j
J ,�G - /nUr�L j �¢Ic e; Q v� 2
Arch.. Engr.. Designer:
Address:
Cit}. ST. Zip:
Telephone:-pe:Construction
State Lic. #:
Name of Contact Person: �At,l i] �7-�1J12�T
T%Occupanc%
Project tnpe (circle one): Net% Add'n Alter Repair Demo
Sq. Ft.: : Stories: Units:
Telephone # of Contact Person:
Estimated Value of Proiect:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRICKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed. ready for corrections
Plan Check Deposit
Truss Coles.
Called Contact Person
Plan Check Bnlance
Title 23 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2nd Review, read• for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
SAM
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