0401-301 (PLBG)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
6486,R1 ril
'� ! filJ�1l2C
Date Signature of Contractor e
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt 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&RC, 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 21 Tag'fE KI N'1) . Policy No. 0460099269.)
(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' comperrsit-ft�pro Iv skons-of Section 3700 of the Labor
Code I steal) foth comp)Y�wltt prgu�S(on
Dated tsLApplicaitt,N,
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 resultof 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 vinth all City, and State laws relating to the building
construction, and hereby authorize rep esentatives of this City to enter upon
the above-mentioned prope )for-insp i n purposes.
I
Signature (Owner/AgenQ---- V' ✓� Date �' ry ' Dl
PERMIT PERMIT#
.BUILDING
DATE VALUATION LOTTRACT
V
JOB SITE
ADDRESS
PALLAIS D S [ir,1^3tW5 .JNJ1 ' �{t).+ D
APN
6451-07% ON?
OWNER
CONTRACTOR / DESIGNER / EN (NEER
Rpt IMC.RR "•1:II314AN
i:::l�Ctk71? 3✓}v`I'C 't�:f�t:iT:1
73-088 Etr 1 11
42-335 VVAHH734C3'IY;)t14 y.l' 0 3'i 5
RM -M. i7FS. ERXr CA ?2260
PA orf. L)3'6e-1Z '
(760)200,4625
USE OF PERMIT
�f 1:.7I�rlj`t:LCJC�
TRENCH I)P_hJN t K) 9N'fERCEI RT ER PER. KY;11SY1 f.) .APPPIORJET)
=� PLAN -9l0JPUMLrHTAL TO 0303.951, 2OP-1 R' 8C,
w
4
1
VAl,tl!•1'I I N 16,000,OD LIS
R1b'M.T_A.' 1) CO't 'I OF CCcvN;E1F�lj(,* fC)J4
16000.00
ll"FW rKI i Erl..:lu.RnWARY
1,15
1"sJ04 (;":I EC K Y1?i? I (i) -G4J- #; •318 $101115
P1:UMBIrdC1FEE 101 _000-419 000 V31 00
A,
L'UB-� KYl:AL (_'09:t'I"1?UC110k4' K141) P.'LA14 CHECK
$144.15
tM03 ?ih_4>A11)FZ.��
;1.00
n tM!ITYX8 DXTENOW
ij A
D 1r.1 k
$144 -JS
04JAN 2 2
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
BY
IN
/
rAT2)TORE
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P. L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Walt Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
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
17
$
Final
COMMENTS.-
OMMERNS: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)
TMMA Qt4 Sj�*L
Bin � Z�City of La Quinta
J L5 l6 ALS Building a[ Safety Division
Permit # rre, t.O..Box 1504, 78-495 Cage TampicoIio n30," Quna, CA 92253 - (.760) 777-7012
Lfv 1-30I Building Permit Application and Tracking Sheet
A Project. Address: qjqrC)sbUrlF'f'l' V�J Q 17 Owner's Name: jtf /1 Wa C✓ pr,
A. P. Number TAddress:
Telephone:, ;- _ -.:� `;: : Construction Type: Occupancy:
State Lic. #: = . f r Project type (circle one): New Add'n Alter Repair Demo
A Name of Contact Person: Ct-16US .(L L ,t t,t,_/?4 Sq. FL: 1 l7 # Stories: # Units:
X
Description:
City. ST..Z.ip:
actor. [-AkruaM EWTrat tt ES-
FTelephonc: .
j(ess:
7 q QQ ( joN ,l
Project Description: ��
7�
ST, ZiP:�►SC"(L} • L%�..a (p O412A1Nhone:�
[dd
Plan Sets
' � �d
'r*t As�js So A -S qb La�i4SLi QZ
Q
Lic. # : (o48 b8 ( City Lic.
Engr., Designer
F .A4C-A NtI5 koL14A QX� S AwAslb f?` OS
AU2— At
l�t(.Lid
�.lr
LJAWAArch., !.
Structural Csks
Address:
T $' 1- t G i -t .T� F d
Reviewed, ready for corrections
City, ST. Zip:
Lc + ��yiti='4s9tL•
Telephone:, ;- _ -.:� `;: : Construction Type: Occupancy:
State Lic. #: = . f r Project type (circle one): New Add'n Alter Repair Demo
A Name of Contact Person: Ct-16US .(L L ,t t,t,_/?4 Sq. FL: 1 l7 # Stories: # Units:
X
Telephone d of Contact Person: - �-�
imated Value of Proje' d
APPLICANT: DO NOT WRITE BELOW THIS UNE
#
Submittal
Req'd
Ree'd
TRACKING
Plan Sets
Phu Cbeck submitted
Structural Csks
Reviewed, ready for corrections
Truss Cala.
Caped Conant Person
Energy Caks.
Plans jiicked up
Flt+od.plaia plea
Purls resubmitted
Grading.plan
V Review, ready for correetionslissut
Subconactor List
Called Contact Person
Grant Deed
Plans picked up
H O.A. Approval
Plans resubmitted
IN HOUSE:-
''' Review. ready for correeti tie
) 22- a
Planning Approval
Caped Contact Person
"l
Pub. Wks. Appy
Date of permit issue
Sebool Fees
FEES
Item
Pias Cbeck Deposit
Pisa Cbeck Balsoce 0
Construction —�--�
Mechanical
Electrical
Plumbing 01
S.I►1:1.
Grading
Developer Impact Fee
A.LP.P.
6i
Total Permit Fees
Amount
37
;I