0205-283 (SFD)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
'740743 :►a !� 09J,30W
D .2, / �. .
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:
( ) 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:
Carrier`�ls6l T't�I~1FIi" i1sS. Policy Na i,`sf1l
(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' compensationpFbvisionse'of Section 3700 of the Labor
Code, I shall forthwith comply with those •t'ovislons.
Date: 7-17- 0 9 Applicant--^%�---�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application•is made & each person ata
whose request and for whose benefit work is performed under or pursuant to '
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)-at ^-�'"" Date —) 7 07
BUILDING PERMIT PERMT#
0:MJ-;}
DATE VALUATION 19117i.Y4R.10 LOT 19 TRACT 24890-4
JOB SITE
ADDRESS ai r
APN
t 2W-0 0-4.31,)7
OWNER
CONTRACTOR /�DESIGNER / EyN51N�yEER
� 4 yam( y ry y� qty Q. }� �� qp�
4..rlSl.'�fl'A, R`A�..1SCLdC )Raw_ii73 �fRltC
A f �y }
'vd9 IrT.'^Ji.l+'•7]�.irlic" E",LO'�.%�,��°.s INC,
4100 NMC A 3°lTUR IST VID 9200
4100'_=vl X t STT r-LVD412.00
ITZI ';f?ORI BEACH CA 02660
N:E°VIOTa BEAK -11 C14, 92€ 60
(9115)6224KOD C"R0 1503
USE OF PERMIT
SFD , WF 1..9, PLAN 1;y.r`. PE U41 -C O0ZS Xar :.M, CLUDE HI SCK `WALL,
F�t� °iy F�.d�. til�I.1;9BG4`9�3�•'v�`'.Pt,'a' ��f�C?t�G'�f• �S�`�J �CT.(��..'i'l.t�i� �'�'i�.e,$����i�G1:
PER, 19 "A IUAC p"'3frO"B. WORIC ifs. U14 vVIO tr31'31i'DIA8GPERDA' °F.
CUSTOM CC3?�IO-i`I33JCT)ON U711100 S.f+
"PORC .IIP,ATIC . 342.00 Sir
XM, .TED C -013A Or,
:F`..RZVffI"i EN 9Ui50/.1A1V
GONSrfkUCTION FEE 101-fi0f'I-118.000 51099.50
PLAfW CI'IY:'CK PE _t
MEf"HKHICAL FEF 101-0100-421-000 %.29-flo
WfrITRICAI., FEE 10)-000-420-00 W4.6
PLUMBING FFX 101,,000.419.000 026,70
S"S TOWN Mt,7TlU'N FEE - Y'a,E31D 101-000-241-000 $131.93
GRADfi* Q r%E. 101.100 -423 -JL''!) 315410
DEVELOPER. IMPACT Fps $zAfoo
ART IN P1.lf$IrIC P1AC-98 - REOi1;,270-000-44.5-0,00 SB0142
INIVESTWA11014.FER `101-000.423-000
R. ViML,9POOIT t�R�f3UtJ-4�5G33� •I;3�A.��
JUL
CITY OFLAQUINTA
FINANCEDEPT, e
RECEIPT
DATE !
BY
DAT FINALED
INSPEC
a
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION -
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
r -
Underground Ducts
Forms & Footings
— -
Ducts
Slab Grade
Q _
Return Air
Steel
Combustion Air
Roof Deck
c7'
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
P _
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
-
Drywall - Int. Lath
_ e:2L
Final
3
Final e,,A
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
-Q2 _
Encapsulation
Gas Piping
Gas Test
Appliances
'L -
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
COMMENTS:
(� 1 (,
h� �A �lL ��/02 c� •G
Nonce (rermi I . — / /—,