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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
637252 02/29;20i
A
Date ignature of Contractor =dim
or V ;,- -
OWNER -BUILDER DECLARATION
I hereby affirm under pena Ity of perjury that I am exempt from the Contractor's
License Law for the following reason: -
( ) 1, 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).
( ) 1, as owner, of the property, am exclusively contracting with licensed
contractors '16 conStruct the project (Sec.. 7044, Business & Professionals
Code).
I am exer�pt under Section _, B&P.C. for this reason
Date Sianature of Owner
VORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have a/nd �vill maintain a certificate of consent to self -insure for workers'
compensatioK, as'provided. for'by Section �3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( JA -have and will maintain workers' compensation insurance, as required by
Sedtion 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.
ROYAL INS. CO. OF i Iff'.8"C' 45.1,�IZ37
(This section need not be completed if t he 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'6ecome subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' comp6nsation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with thos
Date: Iqo 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, indemnity
& 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 for inspection purposes.
Signature (Owner/Agent) . =4m Date
PERMIT#
BUILDING PERMIT
9#07-196
DAVA LUATION S124.3Xi. 30 LOT 91 TRACT 2X60 1, -1
JAN 0 6 200T
JOB SITE
ADDRESS 79-"0 DESEMIL o1IVi1U)W STRE ETI
APN
6451-646,026
OWNER
CONTRACTOR / DESIGNER ENGINEER
.C.ATEUM RESIDE'NRIAL CUNIIMUNMES,
INIC CAIIELLUS USIDENT."AL CO)MMUNT!"IMS,
NC
5 RARK PLAZA. SUUE 400
'i RhRK. PLAZA, SUITE 400
1IM-NE CA 92614
IRME, CA 9261A
5 .6100
(949)?,_1 C13L# '5072
USE OF PERMIT
SINCLE PA.MILY MVELLINC
ViD - LCA 81 PLA -9 3R PENNUT DOES NOT RWUVu- t DLt-.iCK WALL OR
VOOL35%) 11.A14 CHSiCK WIDUCT)ON APPLIW)1-'QR,IVVLflPLE
TRACT CONK;TRUCT 'ON 2,097.00 SF,
PM1 CHIPATIO 12A.00 tili'
GARA00CMUJORT 450.00 SW
ESTMIAlf E, D C08,1v, 011"CO'N'STIRTMON
12411.M6130
PERNOT FEE' SUMMARN"
CON'STRUC7110N F -b -H 101-000-418-000 $1127.00
m. -AN r7mrx"K, FRE !01-000-09-318 $1152-219
ELECTRICAL FEE S 130. 90
Ktim.B1140 V& 101-000-419,000 3160.00
sl�larm(7
Y fvI(jTIoN f -11m, _R!7�q I r 0 (1 -24J-0Q0 $12.41
jj- 00
FIM; 101 -000 -423 -WO S"Aobi)
ART Y4 PUBUC PI -AME - RE -SIP, 701 -000-2534000
DEVELOPRk &IPACTFT�13 $1.9(17.W
AND PtAN CITECK
LESS PRETMEIFEES
vyoo
IDTAL PKRMIT F.C&S 01% NOW
$3�2_36.%
RECEIPT
DATE
BY
I INSPff;
INSPECTION RECORD
OPERATION I
DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 4
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
45
Steel
Combustion Air
Roof Deck e,12 42;?— ev
Exhaust Fans
O.K. to Wrap enz—&-.7E
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
E"'i
Final
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. Test
Final
Gas Piping
PLUMBING A ROVALS
Gas Test
Electric Final
Waste Lines A,
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: