0211-050 (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 B V30/03
Date,�,,qSignature 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).
() 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 L113yRi°ry EeIUl'1j.Aj,F, Policy No. A263L9C04723012TX
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I'shall not employ any person in any manner so as to become subject to the
workers' 'compensation laws of California, and agree that if I should become
.subject to the workers' compensation provisions of Section 3700 of the Labor
.Code, I shall orthwith comply with tho Vi ions.
D'ate'.. Applicana f li9$,/A►.'"-'
...
Warnind: failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addl4ion•t6 the cost of compensation, damages as provided for in Section :1706
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 andfor whose benefit work is performed under or pursuadto
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Qulntajfi 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 Ji
correct. I agree to comply with all City, and State laws relating to the buildigg
construction, and hereby authorize representatives'of this'.City to enter upon
the above-mentioned property for inspection purposes.
,Signature (Owner/Agent)-W. 2 Date/,, �}' u+G...•
BUILDING PERMIT PERMIT#
r._.....-
11
DATE tt tt VALUATION LOT �+ - -- - TRACT
'c wro6r9.��T.�+'..�.�.FV 1 .4°��r ! :��J,��7
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JOB SITE
ADD ESS �80 r29. �g VA ±d1: RJOS .�
APN
OWNER
CONTRACTOR/DESIGNER/EN INFER
TOU a RO1.11MI r 19+
P141M DEPY.alf CA 92260
PAUdL3i�«�i.ff�.'1 CA 5r2260
(760)04-9699 I B14 3831
USE OF PERMIT .,
/yTFA.Rk-
.W(3l2 RAWLY D
'
wFQ • �' 34� SA1�tT0i s1� A—A.. P1�•12MIT > ORS2JC9 `'1 IDL 8� C3C.f'S:
WAi:,r1..S, P001119P.A Ok $;5i$IVWAY APPROACH. i§'1°r, kta)IJOICI `.k O !LAN
CHECK FEE DUP, TO KULTiPIZ ISSUANCE OF S.As.%19 PLAN 9''Y11Z.
1
CUSTOM CONSTRUCTION By
0,0AGWICARPORT 8F
p .wr FEE G 1:m l
CONISTRUCTIO)q FEE 101-000418-000 si.,E83.10
P4AN CHECK F'EIL 101-000-439-318 $260.45
A,4t 9R11?2ICALFRE 101x000.421.000 $118.00
FIFICTRIC,AL IYFV,. 101-000-420-000 $198.32
PLUM i1314OfEft 101-000-419.000 $1"100
S'1"R.0'NO MOTION FI?8-..,RZSJD 101-000-241-000 $211.39
c#RA:rarr O ITS j10 �000M4a 3.000 315,00
WVIQ,,0,PX . IMRACT In',; $2,05,40
Ain zw Pumic Punax - Am 270-000.445.000
�t
ROCTION.4 RD R1.103'l ba .IF.:.
$4.s�i!� ].
ISSS FRE -PAM) FEMS
'40,00
11`
NOV
908.51
L .aFy�,t,
CITY OF
LA QUINIA
FINARiCE DEPT. m
RECEIPT
DATE y
By
DATE FINALED •
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs A
Underground Ducts
Forms & Footings a4oDucts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck Q
Exhaust Fans
O.K to Wrap 'y
F.A.U.
Framing _�7 /6 y $
Insulation"i
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O. At,
Fans & Controls
Party Wall insulation
Condensate Lines
Party Wall Firewall
Exterior Lath • c 57
Drywall - Int. Lath - • 0 3
Final
I-- �%—
_
Final
BLOCKWALL APPROVALS
Steel
POOLS o SPAS
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 �_
/i
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-- .1-2 57
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) - e
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) /
COMMENTS: