0103-051 (BLCK)H
N W
W
o�co
t: LLI T_
I
C Z r`
OO
H 0
LU LU
VJ
Z
co
L0
N
ON
20)
C Q
LOfr
- O
LL
X w —
mVU
O
d rn H
�Z
co =)
�O
Q
J
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
Date 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:
S( I, as owner of the property, or my employees with wages as their sole
ompensation, 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 Treason_
Date; J'� r Signature of Own -. ?^4
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 Policy No.
(Tis 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 subiact to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions o Section 3700 of the Labor
Code I spall fdrthwith comply' th th se p ovislon .
Dater Applicant•
Warning: Failure to secure Workersompensation coverage isnlawful and
shall subject an employer to criminal., enalties 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
the above-mentioned property for inspection purposes.
f Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT# '
DATE VALUATION - ---LOT, f TRACT x '
JOB SITE
ADDRESS
APN.,
S_-08 USENHCAM DUNE
-
OWNER
CONTRACTOR / DESIGNER / EN (NEER
ROXMbW W3ZGIft
R0X MY1r1 VOIi. Wr
2� F. i Sb k fat ,
52•11555a EL�E2T12owRM P M
LA C,�QYi� CA 922 3
L.A.Q7,)NrAt. CA. 92253
(760)564-2722 MIA
USE OF PERMIT
1
V 1....11r. OF 9 tHOR 331.00K WA14 ORC O SY-RTFM
M WAIL 1Y
a
.l "`�i�t4t!rt�'F14"t? #3 Q?i{' (;6?,NF.3iJ£�°F1�LOI�.,?i.`
i"muRy 1A
0014131"+ fit~' ION Y`iE 101-i 00.4143.000 WIN
t<
MAR 0 8 2001
017 Y ui LAU011
S
1
AU13= IAL C`�OM'I'i��.TC� O.0 . A�11) 3�'.i..�.pd C�:�EM, 1
1.00
"
LESS ME PAYD 11M
20100
RECEIP
DATE j
BYDATE
INA
INSPECTOR
)f(.Q�
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 peck
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
Drywrall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Footings—l�
`
Electric Bond
Main Drain
Bond Beam
3_� 3 -Fi r' ��
Approval to Cover
Equipment Location
Underground Electric
Final
_
!�-j -O� ��
Underground Plbg. Test
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
COMMENTS:
1
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. f
Smoke'Detectors
Temp.' Use of Power
Final
Utility Notice (Perm)
Building
Address
P.O. BOX 1504
J5 CALLE ESTADO
, CALIFORNIA 92253
Mailingv r JD� A_e I
Address l
/-7
Tel.
State sic. ' ^/ , I City
&/�o
Classif. Y "h�X Lic. # l
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACT R'S DECLARATION
eb rm that I am I' under pr ions of Chapter 9 (commencing with Section
of 1 ision 3 of the usi sand Pr sions Code, and my license is in full force and
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5.Business and Professions Code: Any city or County which requires a
permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than rive hundred dollars ($500).
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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I ' I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
I am exempt under Sec. B. 8 P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
Copy is filed with the city. ❑ Certified copy is hereby furnished.
L
APPLICATION ONLY
BUILDING: TYPE CONST. OCC. GRP
Number
Legal Description
Project Description
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS' COMPENSATION INSURANCE
/This section need not be completed it the permit is for one hundred dollars ($100) valuationQ _ ci 1,
or less.)
Icertify that in the performance of thg 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. PPLey
Owner . T
Date_
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption you should become ZONE: BY:
f
subject to me Workers' Compensation provisions of the Labor code. you mast forthwith Minimum Setback Distances:/Cp -
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
Iagree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
FINANCE
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation: