0211-047 (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
777699, D 4/30/03
Date/ 1.rZ : Signature of Contracto�� , y""�--•°
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 L.I5ERTY hitlf41'#tl� Policy No. +rl %I7G€t4°9k3A1�
(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 f rthwith comply wit. those.provl Ions,•
�Xpate:/ ,0 2- Applicant •. '�.�_a',/iPa,"g,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
2`
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth ont-',his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless4he City of La Quinta, its'officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days..06rn date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information,is
correct. I agree to comply with all City, and State laws relating to the building
_construction,.and .hereby- authorize representatives of this,City to enter upon;.
the above-mentioned property for inspection purposes.
,-Signature (Owner/Agent)% • �✓ ''r'�'`"'"" Date// • '• 74-
BUILDING PERMIT PERMIT#
"
DATE VALUATION LOT -TRACTJOB
SITE
ADDRESS �e .. V "Vlt�*�,gr m C�$,A,�•
APN ?72-X50-011
OWNER
CONTRACTOR / DESIGNER / EN (NEER
73-12.1 M WAVINQ #100
73 FRED WAtURO ##100
Q60)(3-74,9699 t, r 3832
USE OF PERMIT
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yu111Cf1_-LOT 1k,+�QU.�I"N7"Ri�wq�•..�B.�.+if� 6 •�+t�} {s ,+�y�c. at..Y 49 v •.STP y�,` �p�•.7�
Ulirl LW8, P0014 SPA OR DRIVFWAY APPR().ACN
ti
CUBTQM CONSTRUCTION. M1.21.00 7f
P�'JXpi,G�•iy�yl�ly��.I3M.'.P{I•�O.. 310.00 SP
y p
�a.9?i1.d'�oJY:A M.F.'fil{,1-�R•! ; A!dO.,AV U!'
1
y
k'r=rr FEE 90.14 !I�Aai. Y
CONSTRUCTION FEE 101-000.418-000 s1,xv,00
PLAN C:4tiYWIX M.E 101-00043944146 4l,Fl3'?.H2
MEC.HAMCA IME 101-000-421.000 $12413P
XILECTRIC.Al, PIKE, 101-000420.0-00 SIV.92
1'LIli+ BI NO ''L 101 •-i10(A419-000 $Il ?.00
y'Pii!•f:YI4 O MOTION PEP. • R..S11.0 10 f -000-2A 1,000
MAYNHO FRE, 81S,0>;1
I;AZIELOP R IMPAXT PI
.ART IN PUBLIC' PLACED • AFS r T10 -000 -X15 -t)00 $205,90
Si n-. "C31STRl]MV ,t1N'i ) ;''1'.AN CTTiX,�;:,
$1,46_44
MW 1�fflt-_PAYD ERE'S
$0.00
VVIRMIT AME HOW
au�?
$15,462-M
NOV I
I�
ITY• OF LA WU[Ni6..
FINANCE BE
— - - + - -- - - - - — - • 'ice-'
.
RECEIPT
DATE`y
BY
TE FIN
IN ECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck 3
Exhaust Fans
O.K. to Wrap5-6 -0 3ZiT
F.A.U.
Framing . � .�
Compressor
Insulation , p S
Vents
Fireplace P.L.
Grills
/
Ile
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
,�
Final
Final' L -
POOLS - S AS
BLOCKWA'LL APPROV "
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��1�_ (� iT _
Heater Final
_ _
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection -o i ,
Encapsulation
Gas Piping _
Gas Test I %� ✓ _ _�/
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) .i
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) ��