0301-099 (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
~.y.
674V74f 13 11 ,! M1AD
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).
O I am exempt under Section, B&P.C. for this reason
Date Signature of` Owner '
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
O I, have and will maintain a certificate of consent to self -insure for workers'
compensation, ,as provided for lby Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Se( )' I have and will maintain workers' compensation insurance, as required by
tion 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. MTENWD Policy No. 046-7"000
(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' compensaion.provisions'of Section 3700 of the Labor
Code, I shall forthwith comply with those provislons.t ✓
Date':`- a .y , 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 hi's
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 pursua4to '.
any permit issued as a result of thls'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.'
PERMIT#^ -
BUILDING PERMIT4
DATE VALUATION LOT -I4 TRACT
JOB SITE �' t�n / T p�y•gq,,y�ry�
ADDRESS 911 .i' ONQ I.KE�4Al4�7✓O�ii
APN
�7 nb3.l� 1h�31
OWNER
CONTRACTOR /( (NEER
'1`!7 DI�.�F. J r T9rd'ELOP'aWNT
VAR" i 010"MUC%'iM
PQ tox. 1'7.16
«-'MI RANIMisa LA Q(7INT AIX -L
LNQ177A1IA_. CA 92253
LAQ111 A _ CA 9 253
'
CM)771.1941 CMU 2-596
USE OF PERMIT
7hZU�it FlAurilynw MID
aT''X3 - LOT AA, P,tni0.N M3. PIM iIT ,L OES NOT INCLUrd ; iril1,0C1X
WAIM-1, P0014 SPAI OR, DRIVEWAY APPROACH, 16% REDUCTION TO
R.A.Rs f;hllrl".1C. 3� �2 DUE, TO MULTIF1.2 'ISSUA14CF OF ahME ES`IAX TYPE
cumms c0i4s'ittelo'lom ; . 4,2II;I.;40 Sia4
POR(HiP.f TIO 172.00 SF
€IA,e"3A01YCAR ?OR 710,00 ISS'
SIMW TRD COW We 0CD:LMMUC� ION
-
Yj1,380.30
1Ex
.H.'-.C1r3C.STJG6l 3i`_41!'43.W��ICG JG
COMMRU TIO PB& 101.101 -- ,10t xi :. SIX11$0
PLAN CHWK I`FX 10i«t35`lCd-d3�b52;� `���€3.."f4
MECHANICAL PEP. 101.000,421 -000
Xzl TPUICAL PER. 1014000420-= $7A6.71
I°i31ChQ13NO ?? 1 i1 miJt9t� M11��Ctdt) '�i� ,0t1
vrR>b+$3a'mon4aw7m;; a min )01-000-241,;.000 $ar IA
101-000-4 4' 0003 .. WIN
Ifn
'ART tH POLIC PIA -AC - RESIC Z10-006-445-000 S;te,47
MIE v0%1�"�C3�r 3��Ya
$5,252-05.
JANI ' sFXKW rFMO DUF, NOW
2' q 2003
CITY
OF LA QUJN'(A
w
^BY•
RECEIPTS
DATE. "„
a
D4TEFINALED `
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE ]
INSPECTOR
BUILDING
APPROVALS
Set Backs
Forms & Footings
—�
Slab Grade
— J2 — 3
Steel
- 6, —
Roof Deck
0. K. to Wrap
Underground Electric
Framing
Insulation
/
Fireplace P.L.
Gas Piping
Fireplace T.O.
APPROVALS
Party Wall Insulation
Waste Lines
Party Wall Firewall
Heater Final
Exterior Lath
nnnuall _Int 1 nth
/--
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Retum Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans 8 Controls
Condensate Lines
Final
BLOCKWALL APPROVALS
POOLS -SPAS
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 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
7
Encapsulation
Gas Piping
l
Gas Test
Final _
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Under -around Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
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