0301-072 (SFD)H
;4;L11
O =) CY)
r—,Cy u7
I W
r -
o Z r_
((D 0' O
W W
�a
U)
Z"
i
LICENSED CONTRACTOR DECLARATION
I hereby affirm under'penalty of perjury that I am licensed under provisions of
Cl apter•9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
' License # Lid. Class Exp. Date
Date �' ' `''% Signature of Contractor .�
S
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).
O 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
S ction 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 SfXM 7 0 Policy No. i�1f3-"i 3Z 2f� 3
(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 dl should become
subject to the workers' compensation provisions•of Section 3700,of.-the Labor
1 r.� 7 .N
Code,' I shall forthwith comply with those provisions. t ;
Date:, 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 he 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 x
any permit issued as a result of this applicaton agrees to, & shall, indemnify
•&.hold harmless the City of La Quinta, its officers, agents and employee,
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.) 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 foe'inspection purpos"es. �.
Signature (Owner/Agent)"Y' Date
BUILDING PERMIT PERMIT#
DATE j VALUATION sm,i m LOT TRACT 29293
05
JOB SITE
ADDRESS -7 gyp,; �v,N�:�a�i�,�6
APNSy��> viii I
OWNER
CONTRACTOR /DES16NER7EN (NEER
PID BOX 1716
CA 9=11
LA QTJTA CA 02W
2996
USE OF PERMIT
iOIX. YAML YDWW.,LbT0
SPA) - };.,f d'; P PLAN MI. PERMIT Ut:MNOT INC:t.,ft'D,It flf S>.W.r'tE.L%S
REp�S¢ialCw�i'ft� N ! O PWI CH AM
��'s0�n'JT1, P.�,e+i�?AR i77Rft�f+�yTx+i�ePAYq�.tAf
�P,�P1iZC�?iACK a x°36
�: + R DUE O.LYk�iI7 1PIX U13�]7.f.(NV�..i'I OF oAr M8 i'Ls•7SY tF i PSE '
INS`FOM C_iONOTRUC;TION :.130100 SIS'
P09CHIPATIQ 590.00 SF
r 3Ie C't3 VARYPORT 693.00 g%' .
V. ofi�,'MW COUr OF COP1,5TRU . SON
ne ,IW,SH)
P&MIT ATX SUMMARY
CO NVAUC,T1O! FRE 101.000-418.000. 31;280,00
PLAN FZE RL3�r'fL��a&�.�yp3�tp�+
qli
@�y2dA2�ni
LtliS%v�Ctl.t'lA ICAL•.s ra 101-)00-421-000 a4 b.40,50'
ELMTRICAL FEE 101�000-420,7000 $115.04
t'ilumbrNO IFKA 1O1.a-00 ,41-1-000 $202,25 '
arR, JBa�thfC}' 10.�'s s1x 5�}1�r 101-000.241-000
ORA DMO �1,9 101-000-41'.1-000
isi aMRI3PT�2,4AS.4Ct
Awr W PUBLIC F1ACf!$'- RESir 2"'TiS-000.4.5-00.0 $205.-21
{
... .. ":c co
nwy yy�,rvG
.. �yaj,[;ea r• s pyy � PL
Re.'yi 47€�''i�J.y.l L�.c.oiiiWA`.Pnucrtti�tt .{,�ib'et+� a'.7.�i'm c�:L+4� t,
, �e c,t ee�,
.�iwy�t 64.50
;
a LKIS 11�'2,�, � PAID F013
$0.00
a Y
, 3
JAN 2. 2003
CITY OF LA OWN
FINANCE DEPT .
RECEIPTDATE
BY
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
—/ — 3
Ducts
Slab Grade
3 - —c3
Return Air
Steel
25 .- 3 — 14ts
Combustion Air
Roof Deck
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
Lath
E)derDrywall
Drywllall -Int. Lath
Final j l 2;
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 LinesHeater
Final
Water Piping
Plumbing Top Out
/'_ _
�J
Plumbing Final
Equipment Enclosure
Shower Pans
Z
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
4=/��3
Encapsulation
Gas Piping
Gas Test
Appliances
r
Final
COMMENTS:
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 1
i
i
Final ,- ✓
Utility Notice (Perm) _� -