0303-023 (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
✓Date Signature of Contractor;�� ✓ /•s. �7 — --
OWNER-BUILDER DECLARATION
[ 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. f.
( ) 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 WDERTY MU"t.'U.Mi F Policy No. IYA2621 0472301271:
(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 manher 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 those provisions.
Date: d Applicant i
Warning: Failure to secure Workers' C pensation coverage ,is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety';
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person ate
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless ,the City of La Quinta, its officers,. agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon tS
+the above-mentioned property for inspection purposes.
Signature (Owner/Agent) 0 4574 -4 --_Date Ll `Z
} I BUILDING PERMIT PERMIT#
DATE VALUATION S f i 00 LOT 43 TRACTJOB
SITE
ADDRESS S(( -39) NU "VAfXJt01Ji?t
APN 7^ 24-r ^SAO
OWNER
CONTRACTOR /DESIGNER /ENGINEER
�nLL -BROTEMn
+Jt)%.:dR4mWOkS AC
75, -121 JEER:. "N AM13010.0
13 121 FUD WARI— 0 0100
JAW1 z A �?'IR CA 92260
17Af ,I D4''3rX,'.i CA 2260
C"jCU}t 14-96959 (Nwi .3532
�°
USE OF PERMIT
S170 - Lar 43. Pf'31MI`P is GLYS ''NOT !.'faC2.,LJ13.1+v BIZCK'' 'Yd,AIAZ, POOL,
SPA OR DkIVEWAYAr'PR(Z1ACs-,q•. li%1�►"_P.'o1„i'tv"riap,4 w. PL414 c3a.m ppum
TO AtiliMPL ' & ^4''°'i3a(E N*G OP'!M, , ME MKIN Y YPfK, C�L.i o
. F�O�tY4�lPti"i'yt'2 ✓nI�.UV �A'
�•
GAXAMYCAMIORT O ,Gf) W
iii,,i/T'.,i$a.\;At1IND �COF �7.%t L��i.6��7M+?.i�.I���.�1�.! 1i
4�.'VT,TJi1. 59t.4%� LVA
(; (� yQ��� ^j.�'y g, 7-.
PER.CM.{•$9 .1t.i.1aW b4X1.iYS.{VR.J1, .7.
CON19T111"UC'4'KiN n. E 1 �I.�tFt)Ci�413,;7tiQ ,f,��C+, 4
PLA.1 l:I'IEi.',K rR
i►Q1 P.•.'4 1 'l11r ,i 1? 101.000-421-000 S124.50
_
F?J. W,,C',i'Rrr'A.L IME 101-000-42,0-000
PL-1JM.11IN01'41.E 101-000-4'19.000
STIR0140 A9t39' ON T17% d RS= 101-000.241-000
00-4,23.000
GRADING 1ri'.R 101-000-4,23-000
I3PVTEI.OF, R. iNITPACT f'BI -
,ART IN PU11VIC PLAM - RE811r.. 27,9.E. 00 5.000 V65196
• � :�� � ��. t:�ez � �•�1:�r�: ; � . � ��r�� >��µ�la� tr^t�:�fCl�
�a,f,€��,��
UO3 PIM—VAW;3��?,,'�
$0.100
APR 1%3 01 -1 : _rr .ODw=h,.c
CITY OF LA QUINTA `
FINANCE DEPT.
r.99
RECEIPT
DATEVFAtr
FINA NSPEC R
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
✓
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
✓�j
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wali Insulation
Condensate Lines J
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL 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
5- 41-0.3
Heater Final
Water Piping
_�
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
5- ( -a
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
—�T—✓
Fixtures
Main Service
Sub Panels
_
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) 45S 6 e /
V — - -