0311-243 (RC)P
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurythat I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
46,0356 D Hie 10/3112(
Signature of Contractor
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&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:
STAYS FUND Policy No. , 1615446-2003
(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
CoOe -I shall forthwith comply with those provisions.
Bate: ' '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 t� at the above information is
correct. I agree to comply with all City, and State I4ws relating to the building
construction; arrd-her y author representatives of this City to en r upon
the above=mentioned property �r Insp ctlon pure ses.
Signature (Owner/Agentl. �!'- Date
LX
BUILDING PERMIT PERMIT#
DATE VALUATION LOT '` TRACT
PAR 2
1-
JOB SITE,
ADDRESS afi�_MUZ PA W RM
APN f 4 -i130 (D: f3
OWNER
CONTRACTOR / DESIGNER / EN (NEER
BARTPhi R -
T.F1:IiY.t1 CC 1Q 1??LlC°T 9A
PO BOX 7750
3065 F VERO dAPXI
MEWPORT B1 AC13 CA, 92658
73ALM LrPRIM30 CA 92262
(760)320.2113 C31A TBD
USE OF PERMIT
COMMERCIAL RRIODEL
ADDITIONAL COMM..C-RCW, S112f L WORK TO 10,384 S.F. ONLY -
SLIPPLF.R,'1ENT TO PERMIT 0201-243 [SHELL KDO 19 X3,184 S. F. �
(EVS1 OCCUP.J114CY, TYPEV-N).+. NO OCCUPANCY CO.
VALUATION 8.500100 LS
X8Fr MATi1) C0S*F OF C019MY7C'y' MON
€I�ATiiS+.Q�
P�'1I21>dii' x t�'0`Mi►,tfi#4.RY :. .
PI -AN CH1r X TWI 101-000A'39•316 $70.20
COI YrRUCTION FEK' 101-000.4113-000 31CIO. 00 ,
MWHA411CAL IEE 101-000--421-000 $46.00
1£[.FC'1.R1cAL. F 101-(100.42D-000 14.00
n
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I'
NOV 2 5 2003
Cf TY Gr ,. 4: riK'SLI
SUB -TOTAL CO3dMC1CF ON AND PLAN r-MCEC
LW3 PRE -PAID FUS
VAN)
T01A PXMW lis DW; R0W
RECEIPT
DATE
BY y�� j
DATE FINALED
INSPECTOR
..'-.INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE'°' .;- 1NSRECTOR
BUtLDING _ 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. 4.
Grills
Fireplace T.07
Fans & Controls
'
Party Wall -Insulation
Condensate Lines
-
Party Wall Firewall
Exterior Lath
_ -
Drywall - Int. Lath
Final
Final
RLOCKWALL-APPROVA_ LS
steel
POOLS - SPAS - -
Set Backs -=
Electric Bond
Footings
Main Drain
� = -
Bond Beam -
Approval -to Cover
: La �.. I"•
'
Equipment Location
'
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS— :.
Gas Test
Electric Final
Waste- Lines
Heater Final
Water Piping
'-Plumbing Final
7
Plumbing Top Out
Equipment Enclosure
--
Shower Pans
-O.K..forfinish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
.Gps Pipi
Gas Test' -
—
Appliances
_
Firialf
Final
Utility Notice (Gas)
ELECTRICAL'`APP96VALS
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
FinaO
Utility Notice (Perm)
COMMENTS:...:
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=DING a SAFETY DEPT.
APPROED
FOROUvatez-__/49.;:. rip
A RE -INSPECTION fEE Of $30
WILL BECHARGEDIFDIE APPROVED
PLANS AND 10B CARD ARE NOT ON
THE SITE FOR A SCHEDULED
"AN ADEQUATELY SIZED DEBRIS CONTAINER
IS REQUIRED ON THE JOB SITE DURING ALL
PHASES OF CONSTRICTION AND MUST BE
EMBED AS NECESSARY FAILURE 10 DO SO
MAY CAUSE THE C IY TO HAVE NE CONTAINER
Dt1MPED At THE DAZE OF THE OWNER/
CONTRACTOR"
CONSTRUCTION HOURS
October lst - Aprii 30
N/onday - Friday: 7:00 a.m, to 5:30 p.m.
Saturday: 8:0O am. to $a0D p.m.
Sunday: None
G ove t ment Code Uo1Idayi l None
May lst- September 30th
Monday - Friday: 6:00 a.m. to 7:00 p.m.
Saturday: 8:00u.n to5:00,p.m.
Sunday: None
Government Code Holidays: None
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