0101-340 (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
41MRIV.
Date Signature of Contractor==:M,7__
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
( ) 1, 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).
( ) 1, as owner of the property, am exclusive ' ly contracting with, licensed
contractors to construct the project (Sec.* 7044, Business & Professionals
Code).
I am exempfunder Section' or
B&P.CA this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm 1.5rid& penalty of perjury one of the following declarations:
I have,and.il 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.
(This'section need not be completed it 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 1. should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code sfiall forthwith comply with tm ose provisions—
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is -,unlawful and
shall subject an employee to criminal penalties and civil fines td $100,;000, in
dw.
addition to the cost of compensation, damages as provldedjfor
iffiSectioh 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person ail'
whose request and for whose benefit work is performed Under or, pursuaAtto'-
any permit'issued,as a result of this applicaton agrees to, & shall, indemnify
& hold harmless "the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes nuliind void if
work is not commenced within 180 days from date of issuance`OT such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioried property for inspection purposes.
Signature (Own er/Age nt)�d/L"_� a
PERMIT #
BUILDING PERMIT
DATE VALUATION LOT. TRACT
0101,-' 340
1 41. 23W. I -I
I
JOB SITE k
APN
ADDRESS
1450'VIA co,
:'11-.022
OWNER
CONTRACTOR DESIGNER ENGINEER
0 R-MIRYA W-MANDEMLOPNYWT, CKY
1P. (_%,VMRY A10MJCfiAJ DIZVE1 P. I", .1U, C Of
C -467 30TVITTY"', MW �s
55
55-4.87 WILYTHEMR-111W)
LA QUfN-TA C -A 922,53
LA, QUNTA CA 92213
(760)564P5612 C. 54V7
USE OF PERMIT
SWOU- - FARMAMWE11 MG
SFO -LOT 4$ PLANW1CP , PERMIT DOES NOT fNCLXMXBLQCX
WALUPOOLN, PA O.R.APPROACH DR.IYRWAY.1504 MAN CHECK. wl'
REDUCTIO14 FOR, MULTIPLU ISSUANCE OF SAMEPL.A.NkTYPE
TRACT C-614STA3.3iION 2,461,00 sw
PORCIEUPATiO 454.00 SP
12,328,40
4.
cogr
'?,1KwvaT rim sum. my
CONSTRUCTIOA ME. 101fYX1-411BmQ00 $821.5.0
PLAN CHF -CK PEE 101-000-439-�18
M WHAWICAL FEE 1X31.000••421 -QOM MOO
ELECTRICAL FEE 10.1 -000-420-000 23
PLUMBINGF&"-.= 101»000-A19'•000 $168.30
srtowf k94 -51D 101-0004AI-000
GRAD1901 -000-4234%
El x., I P - .-VF 1,�CY7 ata
E
IAN
A
ff OM -rarAL C ON.WRIJ CID OX 1'x:0 P1 CHECK
14A
' J
1 X3 3 k R Y -PATD ROD
Vwo
IYOTAL rMWITI FIK 8 )JOE N ow
V,314,00
RECEIPT
DATEDATE
FINALED
INSPECTOR
Y
P.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs _
Underground Ducts
Forms & Footings
�
Ducts
Slab Grade
2
Return Air
Steel_
Combustion Air
Roof Deck
tl'1.(
Exhaust Fans
O.K. to Wrap
CQv
F.A.U.
Framing
! CJ (
Compressor
Insulation
��
_
Vents
Fireplace P.L.
_ _ _
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Q
��
Drywall - Int. Lath
//
Final `�. //
Final
POOLS - SPAS
BLOCKINAL�6.
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 Lines
2`�
►��
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans(Q_
O.K. for Finish Plaster
Sewer Lateral
�gQD7L
Pool Cover
Sewer Connection
-(�
Encapsulation
Gas Piping
Gas Test
Appliances
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
Final
Utility Notice (Perm)