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LICENSED CONTRACTOR DECLARATION
1 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 # 21ic. Class Exp. Dg@/3M
LDato � �r�i� Signature of Contractors k1"u' }"I
0
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.
C,x) -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. Mworkers' compensation insurance carrier & *Policy no. are:
Carrier STATFE F�1 D CONW. Policy No. 0r`4� 0Oi,"2i i
(This sectionneed 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 `;
,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
the above-mentioned property for inspection purposes.
IF�
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Signature (Owner%Agent Date .•��`�- � �� ''�'�"''
BUILDINGP!:RNIT PERMIT#'fit}d}_ftm
o9n 1!F J
DATE VALUATION LOT TRACT
ORA tt_g-, X'`'_-.._
__a _
JOB SITE
ADDRESS
APN
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OWNERi.)7� 1SJC�I : {:L"LL.I1,r.r ).�.
CONT.�jACiTORENGINEER
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40 96OChL .FORMA O.4ki:,S ELO.AD 9143
amp, CA 9211.
1ILF RIETA CA 92562
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NEW i 141 a fA ft AKTPI�i'f,TA Si�FFt�I - Ttnt't s
l:t_t1'# it�%3 �)f' st�i'I�f��4t6sAda'
ONTO ROOF
V.ALU.al„.3ON 60,000.00 Vil
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Ct',}f+f- YCITION FR71 101-0011141"."(11 . 3454.50
NIEC.T.�� NI C'Al. F -M 10-000-1MI $90.00
1:1XV,TR,fCA(, FM, 10 x -000-420-000 SS& so
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T LOT ., F'ERMI "FG� EN .F3IA,' NOW
$912.68
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
(!s - Z7 4fr !;r ,
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
.Party Wall Insulation
Condensate Lines
'Party Wall Firewaili,,
Exterior Lath
Drywall - Int. Lath
_ r'f 5
`D -?-47
� N.9r G• � /o - l$- $ �t S
_
Final to �4 �%
BLOCKWALL APPROVALS
Final
;3 '�;` ' r!4'; r�,, ' POOLS SPAS
Set Backs
'Electdi'"
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
'-' ?kms k
- Equipment Enclosure
Shower Pans
LOX for Finish Plaster
Sewer Lateral
; Pool Cover,
Sewer Connection
=`.ri ;
`.Encapaulatioh
Gas Piping
Gas Test
Appliances
Final
COMMENTS:`
+
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring (o _ S
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final l�
Utility Notice (Perm)
Bin#
City of La Quinta
Building 81 Safety Division
P.O. Box 1504
78-495 Calle Tampico
La Quinta, CA 92253
Building Permit Application and Tracking Sheet
Permit #
Project Address: _ '� 0 C�'1e a
Owner's Name: A,, -
A. P. Number:
Address: rQ Ray 19707
Legal Description:
/
City,ST. Zip: ' (V 1 11 P CA q 2-7/3 7
Contractor:
Address:
Telephone:
Project Description:
City.ST. Zip:
V)G' t iw f vr✓tci -
Telephone:
State Lic. _ :
Cin• Lic. s:
Arch.. Engr.. Desisrter:
Address:
Cit\. ST. Zip:
Telephone:
State Lic. _:
'game o1 Contact Person: 3e q -C Poeck
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: #t Stories: # Units:
Telephone = of Contact Person: (
Estimated Value of Project:
APPLICANT: DO NOT WFUTE BELOW THIS NE
d
Submittal
Req'd
Reed
TRACKING
PE#ZMiT S
Plan Sets
Plau Chftksubmitted
Item
Amount
Structural Cala.
Reviewed, ready for cotmtions
Pian Check Deposit
Truss Caks.
Calkd Contact Person
Plan Check Balance
Title 24 Cala.
Plaus:picked up
Construction
Grant Deed
Plans resubmitted
1
Meebanical
School Fees
Reviewed,'ready3o.issae
Electrical
Subcontactor List
Called CgntactPersou./
p`ZD "t
Plumbing
Coarractor Info.
Date;ef permit issue
S.M.L
Civ Business Lic.
Gr&diag ..
Workers' Comp.
Tnfr strnctard:
Planning Approval
ti :
Rq ::
Pub. Wks. Appr.
H.O.A. ApprovaE
Fire Man Appr,
H. Dept. Approv:l
Ag. Approval
Date affinaliuspection `
Tow'permitvees
City of La Quinta
Building a Safety Division
P.O. Box 1504
-495 Calle Tampico78
LaQ uinta CA 92253
Tracking
Buildin Permit Application andTrack
Project Address: q.
o 73 oCna(e.
Owner's Name: r�.
A. P. Number:
-- t
Address: 7L+ EL
Legal Description:
City,ST, Zip:2 7 -
Contractor.
Telephone:
Address:
Project Description: l
Ciry.ST, Zip:
Telephone:
—4City
S W H'
State Lic. # :
Lic. #:
Ub(� (� e (�e " �MuUv1i
Arch., Engr., Designer:Jaf
e -0 r, 4 eo G .5
w -I 4kAe-ju+ n
Address:
714 -
City, ST, Zip:
Telephone:
Construction Type: Occupancy:
State Stoto Lic #
-
Project Ject nP (circle one):: New Add' n Alter Repair Demo
—7 -
Name of Contact Person:
• �J17i
Sq. )Ft.:
#Stories: T#
Units:
Teleahone # of Contact Person: a <�
Estimated Value of Proiect:9 _���
i
Cc"r'.. Dev,
City of La Quinta.
Developers Project Approval Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
meter approval. Contact applicant for resolution of conditions preventing or delaying approval.
Project: Telecommunications antenna & equipment (drawings attached)
La Quinta Library building
78-080 Calle Estado
Applicant Contact: Ernie Courter, Airtouch Cellular, (949) 222-7656, (714) 542-7500 (cell)
Application /Circulation Date 4/z8/'f
Da e
Community
Department
Iorio, Planning
Public Works Department
*** NOT REQUIRED, PER MARK HAROLD ***
Steve Speer, Senior Engineer
Building and Safety Department
Mark Harold, Building and Safety Department Manager
Health Department
Date
Fire Department
Date
Schools Fees Paid
9 /z -c)/
Date
Date
1 1
Date
Date
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