0212-128 (AR)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
777699 4A, 0103
Date - Signature of Contractor" =
t OWNER -BUILDER DECLARA ION
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 )a)T3RTY1AUT1.1&,?. Policy No. v"�"n'a'.�6IIfEll ,rl�ttw�h`i
(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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date:PApplicants .
/ -. ,
Warning: Failure to secure Workers' Comll6nsation coverage is unlawful and
shall subject an employer to crimin0penalties 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: -
�Signature (Owner/Agent 04 I Date I el
` BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
10
J013 SITE� ADDRESS a} : i. tom✓ E� �n �. a.C�% �.
APN 'I.17,2g)-tun I
OWNER
CONTRACTOR/DESIGNER/EN &NEER I
21 PIP M NVARMY 03. 00
11REDW41ZING1#100
PALM10 CA 922.60
PALM D'LIZUT CA 922640
USE OF PERMIT
MISMEN�';t1! L ADDITION
StlPPLl?,3+Lf704TAL TO PERMIT it 01111=M, ,r101'JINO 307:,.I?: OASITA TO
CUSTOM CO-3+1i9'i RUCTICM ali
PERMIT TM -9 WNWidZy
COMSTr.1XE.°T]UH I FT, z M _0004 f %-000 5243100
PI—AN CHECK PEE 101-000-439-318 $197..Iq
MEMAY41CAL FEE 101-000-421.000 $11GitG
XL1ab'a'd°IgICAI,.'I £(11-ittd20�ta0a $ 3S.'%
PL11M0.11-TO WE 101-000--419.1000
STR-MO MPTION M - PY.51 i 101-000-241-000 $2.39
01AD111aFE011 101-0i10,.47.3.0 alt Wroo
ART 114 P1351,10 PLACES • RZ,31'L 270•(}Clt1••445••000
,• . r ,kms r `:_Jl, 2�O �.A�1:91y�T A!� �fi1� ��
$611.1 3
M33 PM -PAR) 1MR-01
WOO
JAN 14 10031"D / , rMVIr I'M,,; DUIE NOW
$6111 rl.4
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATEBY
_
FI '�
INSPE TO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE —T
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
.p
Exhaust Fans
O.K to Wrap
o S'1
F.A.U.
Framing
Compressor
Insulation
S .
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
. o "j 97
Final
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
3:24-40 3 S,T
Encapsulation
Gas Piping
Gas Test
Appliances
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
Utility Notice (Perm)
COMMENTS:
c8 85.00' � c9
O TW 34.10
1 �� TF 27.10
nc' 0.50% : - o
PAD = 282 0.50% f
TW 34.10
TF 27.10
6' PATIO : 9'
X80-15� 5 VIA VALEROSA Q '
_ FF = 29.10
PAD = 28.6 Cl
VENTANACD
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�SEWER
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GRAPHIC SCALE
20 0 10 20 40
( W FEET )
1 inch = 20 ft.
UNDERGROUND UTILITIES
ALL UNDERGROUND UTILITIES OR.STRUCTURES REPORTED BY THE OWNER OR
OTHERS AND THOSE SHOWN ON THE RECORDS EXAMINED ARE INDICATED,. WITH
THEIR APPROXIMATE LOCATION AND EVENT. THE OWNER, BY ACCEPTING
THESE PLANS OR PROCEEDING WITH IMPROVEMENTS PURSUANT THERETO, AGREES
TO ASSUME LIABILITY AND TO HOLD UNDERSIGNED HARMLESS 'FOR ANY DAMAGES
RESULTING FROM EXISTENCE OF UNDEPGROUND UTILITIES OR STRUCTURES NOT
REPORTED TO THE UNDERSIGNED, NOT INDICATED OR SHOWN ON THE RECORDS
EXAMINED. THE CONTRACTOR IS REQUIRED TO TAKE DUE PRECAUTIONARY
MEASURES TO PROTECT THE UTILITIES DR STRUCTURES SHOWN AND ANY OTHER
UTILITIES OR STRUCTURES FOUND AT THE 'SITE. IT SHALL BE CONTRACTOR'S
RESPONSIBILITY TO NOTIFY THE OWNERS OF THE UTILITIES OR STRUCTURES
CONCERNED BEFORE STARTING WORK.
1
PRIVATE EN(
CONSTRUCTION CONTRACTOR AGREES
ACCEPTED CONSTRUCTION PRACTICES,
REQUIRED TO ASSUME SOLE AND COh
CONDITIONS DURING THE COURSE OF
INCLUDING SAFETY OF ALL PERSONS
SHALL BE MADE TO APPLY CONTINUO
WORKING HOURS, AND CONSTRUCTIO
DEFEND, INDEMNIFY AND HOLD DESIG'
'ANY AND ALL LIABILITY, REAL OR ALL
PERFORMANCE OF WORK ON THIS PR
FROM THE SOLE NEGLIGENCE OF DE_
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